LIBRARY OF CONGRESS, 



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UNITED STATES OF AMERICA. 



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GASTRIC DERANGEMENTS. 



HORSFORD'S ACID PHOSPHATE. 



Unlike all other forms of phosphorus in combination, such as dilute 
phosphoric acid, glacial phosphoric acid, neutral phosphate of lime, hypo- 
phosphites, etc., the phosphates in this product are in solution, and readily 
assimilable by the system, and it not only causes no trouble with'the 
digestive organs, but promotes in a marked degree their healthful action. 

In certain forms of dyspepsia it acts as a specific. 

Dr. H. R. Merville, Milwaukee, Wis., says: " I regard it as val- 
uable in the treatment of gastric derangements affecting digestion." 

Dr. E. Osborne. Mason City, la., says: " I consider it a valuable 
addition to the remedies in use for the relief of gastric disorders depend- 
ent on enervation." 

Dr. Albert Day, Superintendent of the Washington Home, Bos- 
ton, says: " For several years I have used it in cases of alcoholism and 
gastric irritation. It is of special value." 

Dr. T. G. Comstock, of the Good Samaritan Hospital, St. Louis, 
says: " For some years we have used it in a variety of derangements 
characterized by debility, as also in chronic gastric ailments. It is ap- 
proved of, unanimously, by the medical staff of this Hospital." 

Dr. G. W. Whitney, Marshall, Minn., says: "I have used it in 
debility of the nervous system, and deranged condition of all the secre- 
tory organs. I esteem it highly." 



Send for descriptive circular. Physicians who wish to test it will be 
furnished a bottle on application, without expense, except express 
charges. 

Prepared under the direction of Prof. E. N. Horsford, by the 

RUMFORD CHEMICAL WORKS, Providence, R. I. 



Beware of Substitutes and Imitations. 

CAUTION: — Be sure the word " Horsford' s ' > is Printed on the label. 
AXl others are spurious. Never sold in bulk. 



X 



$ 



CANCER, 



AND ITS TREATMENT 



BY 



DANIEL LEWIS, A.M., M.D., Ph.D., 

Surgeon to the New York Skin and Cancer Hospital; Pro- 
fessor of Surgery (Cancerous Diseases) in the New 
York Post-Graduate Medical School. 



' r 



£*w. 




ttSXiqy^W 



/ 



1892. 
GEORGE S. DAVIS, 

DETROIT, MICH. 






' 



Copyrighted by 

GEORGE S. DAVIS. 

1892. 



CONTENTS. 



CHAPTER I. Page. 
Definition of Cancer — Medicinal Agents — Chian Turpen- 
tine — Chloride of Aniline — Pyoktanin — Snow's Clas- 
sification - i 

CHAPTER II. 

Development of Cancer from Non-Malignant Diseases — 
Warts — Moles — Sebaceous Tumors — Simple Ulcers 
— Syphilitic Ulcers — Phimosis — Umbilical Hernia. . 10 

CHAPTER III. 
Development of Cancer from Non-Malignant Diseases 
(Continued) — Psoriasis — Ichthyosis of the Tongue — 
Leucoplakia — Eczema or Paget's Disease of the Nip- 
ple — Remarks on the ^Etiology of Cancer 25 

CHAPTER IV. 

Remarks on Diagnosis — Clinical Features Sufficient — 
Microscopical Examination Valuable for Prognosis 
— In Doubtful Cases Treat the Disease as Cancer.. . 31 

CHAPTER V. 

Epithelioma of the Skin — Treatment by Mild Cauteriza- 
tion — Escharotics — Jennings' Potash and Cocaine 
Paste — Lactic Acid Paste — Marsden's Paste — Bou- 
gard's Paste 37 

CHAPTER VI. 

Epithelioma of the Eye-lids — Lower Lip — Treatment by 
Caustics — Operation — Epithelioma of the Tongue — 
Kocher's Operation — Whitehead's Operation — Prog- 
nosis Always Unfavorable 46 



VI 

CHAPTER VII. Page. 

Cancer of the Female Breast — Frequency — Etiology — 

Clinical Features — Diagnosis 59 

CHAPTER VIII. 

Cancer of the Female Breast (Continued) — Treatment- 
Caustics Never to be Recommended — Operation — 
Details of— Dressings — Results — Cancer of the Male 
Breast 70 

CHAPTER IX. 

Cancer of the Uterus — Early Diagnosis the Only Hope 
for the Patient — The Pre-cancerous Stage — Treat- 
ment — Caustics — Total Extirpation — Disinfectant for 
Patient's Room 82 

CHAPTER X. 

Cancer of the Rectum — History of a Case — Causation — 
Examination of Rectum — Symptoms — Treatment — 
Care of Incurable Cases 9a 

CHAPTER XI, 

Unusual Cases of Cancer — Sarcoma of Scalp — Epitheli- 
oma Involving the Wrist Joint — Epithelioma of 
Back of Hand — Excision of the Breast under Co- 
caine , 99 

CHAPTER XII. 
Remarks on Author's Five Hundred and Thirty-four 
Cases — Location of Disease — Treatment— Results — 
Is Cancer a Febrile Disease ? — Bibliography 105 



PREFACE. 



This volume contains the essential features of the course 
of clinical lectures delivered at the New York Post-Graduate 
Medical School on the subject of Cancer. The deductions 
here published are based upon the study of 534 cases, occur- 
ring in my service at the New York Skin and Cancer Hospital 
and in private practice. Within such narrow limits it is im- 
possible to include even a synopsis of the entire subject of 
Cancer, and, therefore, the discussion has been limited chiefly 
to such topics as bear directly upon the successful treatment 
of certain forms of the disease. 

Some comparatively new methods of treatment are de- 
scribed, as well as modifications of usual methods in the 
management of certain cases, which have been proved to be 
valuable. The employment of caustic applications has re- 
ceived considerable attention, and the cases in which their 
use is advisable, as well as those in which such means of 
treatment are inadmissible, have been indicated. 

It has been my purpose to reiterate the importance of 
making an early diagnosis, to be followed by prompt and 
radical efforts to remove the disease, even in the precancer- 
ous stage, with the firm conviction that the appreciation of 
this necessity by both patients and physicians will soon place 

Cancer in the list of curable diseases. 

D. L. 

249 Madison Ave., New York, 
February, 1892. 




SARCOMA OF THE SCALP. 



CANCER AND ITS TREATMENT. 



CHAPTER 1. 

DEFINITION— MEDICINAL AGENTS— CHIAN TUR- 
PENTINE—CHLORIDE OF ANILINE— PYOK- 
TANIN— DR. SNOW'S CLASSIFICATION. 

The term cancer is a convenient one for general 
use, provided we have a uniform understanding as to 
its application. In the following pages all malignant 
neoplasms are denominated cancer. 

Dr. Herbert L. Snow has given the following 
characteristics of cancer:* 

i. Resistance to all known medicinal agents. 

2. Proneness to invade other organs and tissues 
of the body than those in which it has originated. 

3. Liability to recur after removal by caustics 
or the surgeon's knife. 

4. The pain to which it commonly gives rise. 

5. The tendency to destroy life. 

Although there are widely varying degrees of 
malignancy, depending upon the condition of the pa- 
tient, the location of the disease, and the variety of the 
structure of the tumor itself, yet all will agree that 



* Clinical Notes on Cancer. 

I DDD 



the characters enumerated, when found in a given 
case, are sufficient for the clinical diagnosis of cancer. 

The researches of the microscopist have deter- 
mined with some degree of accuracy the minute 
anatomy of the different varieties of malignant 
growths, but the fact remains that the surgeon must 
almost invariably base his treatment upon the gross 
appearances and clinical history. 

The first characteristic named, " resistance to all 
known medicinal agents," may in the near future be 
modified by the experiments now being made with 
new medicinal agents. A brief review of our experi- 
ence with some of them may be profitably considered. 

I. CHIAN TURPENTINE. 

This remedy, the internal administration of which 
as a remedy for cancer has recently been recommend- 
ed anew by Professor John Clay, obstetric surgeon to 
the Queen's Hospital, Birmingham, England, is a 
product of the Pistacia terebinthus, a tree which in its 
native island of Scio, in the Mediterranean, grows to 
the height of thirty or forty feet. The gum is ob- 
tained from incisions into the bark, and the many im- 
purities which it contains are composed of sand, 
leaves, straw, and particles of the bark and fruit. As 
Professor Clay insists that its efficiency depends upon 
the genuineness of the drug, it is well to carefully 
consider the following description from Fliickiger and 
Hanbury's " Pharmacographia " : 



— 3 — 

"Chian turpentine, as found in commerce and be- 
lieved to be genuine, is a soft solid, becoming brittle by 
exposure to the air; viewed in mass, it appears opaque 
and of a dull brown hue. If pressed while warm be- 
tween two slips of glass, it is seen to be transparent, of 
a yellowish brown, and much contaminated by various 
impurities in a state of fine division. It has an agree- 
able, mild terebinthinous odor, and very little taste. 
The whitish powder with which old Chian turpentine 
becomes covered shows no trace of crystalline struc- 
ture when examined under the microscope." . 

It is believed that Strassburg and Venice turpen- 
tine and Canada balsam are often substituted for it, 
which can easily be detected by applying the tests as 
to taste, odor, and appearance given above. 

The turpentine, as used by Clay in his first re- 
ported cases,* was given in the form of a pill, con- 
taining three grains, combined with two grains of 
flowers of sulphur. Two of these pills were given 
every four hours for many weeks, and in some cases 
for nearly a year. It was found that in. some in- 
stances the turpentine in the pill form was not well 
digested, and the latest recommendation of Professor 
Clay is to administer it in the form of an emulsion 
made as follows: 

One ounce of the Chian turpentine is to be dis- 
solved in two ounces of sulphuric ether. This solu- 

ft 



* Lancet, March 27th, 1880. 



tion has been termed the turpentine essence, and the 
emulsion is made by adding one ounce of this essence 
to a mucilage of acacia (one ounce and a half of 
powdered gum Arabic and water to nine ounces), 
making a ten-ounce mixture, a teaspoonful of which 
contains about three grains of the drug. A dessert- 
spoonful, it will be observed, contains the same 
amount of turpentine as the two pills which were pre- 
viously recommended. In some cases resorcin has 
been added in doses of a grain. This emulsion is 
not of a disagreeable taste, as nearly all of my pa- 
tients who are under the treatment testify. 

Tonics have been used when indicated. In some 
instances local applications have been made, in others 
this internal remedy alone has been employed. When 
it has been taken for about three months it should be 
omitted three days in every fortnight. The sulphur 
is often given in a separate pill, especially in cancer 
of the uterus and rectum. I have given this descrip- 
tion of the plan in order that we may have an ac- 
curate knowledge of what this Chian turpentine treat- 
ment really is. 

We are all familiar with the statements which 
Professor Clay has repeatedly made concerning its 
efficacy. He has seen a number of complete cures, 
not only of uterine cancer in advanced stages, but 
also of cancer of the rectum and surface epithelio- 
mata. In cancer of the breast he reports marked im- 
provement of symptoms and complete arrest of the 
new growth. 



— 5 — 

tyo report has yet been published, as far as I can 
learn, stating the precise changes in the tumor, but 
he maintains that the primary action is upon the peri- 
phery of the growth. The plan has been tested in 
the London Cancer Hospital, and, after a tolerably 
thorough trial, condemned by Dr. Marsden and Mr. 
Purcell. Another trial has recently been made, how- 
ever, and one of the surgeons of the same hospital 
declares the Chian turpentine to be a very useful 
remedy in many cases. 

Several patients in my service in the New York 
Skin and Cancer Hospital were placed upon the 
treatment early in 1888, and it was faithfully followed 
in eight of them for periods varying from three 
months to two years. Two were uterine cases; one 
of these was not affected in the slightest degree. 

The other came into the hospital with extensive 
ulceration of the cervix. There were three nodules 
in the vaginal wall, evidently cancerous. The patient 
was anaemic, sleepless, irritable; haemorrhage was of 
daily occurrence, and pain almost constant. Without 
the employment of any local treatment except carbol- 
ized douches^ in twelve weeks the haemorrhage and pain 
had ceased entirely, the va'ginal nodules had become 
soft, and the ulcer of the cervix was half its original 
size and seemed to be a healthy granulating surface. 
The patient believed she was well, and we were unable 
to prevent her return to her home. Three months 
afterward she was re-admitted with the disease again 



— 6 — 

active, and nothing impeded its fatal progress. It 
seemed certain that the marked improvement in the 
first instance was due to the drug, and I regret ex- 
ceedingly that the experiment was interrupted. 

One patient with extensive epithelioma of the 
face showed decided arrest of the ulceration, and gen- 
eral improvement in symptoms, as well as in the ap- 
pearance of the diseased surface. No absolute cures 
were effected, but I yet employ it in some cases, be- 
lieving that it is of sufficient value to hold a place in 
our meagre list of internal remedies for cancer. 

2. CHLORIDE OF ANILINE. 

In. June, 1891, my attention was called to the 
chloride of aniline by Dr. C. E. Bruce of New York, 
who had observed a marked improvement in a cancer 
of the tongue following hypodermic injections of 
from ten to twenty drops of a ten-per-cent. solution 
(in dilute alcohol) repeated about twice a week. The 
injection had been made in the arm or between the 
shoulders, and when carefully done produced no dis- 
agreeable effects. After a few weeks' treatment, pain 
was relieved, infiltration was diminished to such an 
extent that the patient could protrude the tongue 
(which was an impossibility before the injections were 
commenced), and swallowing became much easier. 

A laboring man, aged 55, entered my service at 
the Skin and Cancer Hospital six months ago with an 
epithelioma of the tongue on the right side, about 
one and a-half inches from the tip. At the border it 



— 7 — 

was ulcerated, and the hardened tissue beneath the 
tongue was continuous with a new growth the size of 
a robin's tgg f which protruded below the body of the 
inferior maxilla. Pain was a prominent symptom, and 
swallowing was both painful and difficult. Had this 
case followed the usual course, its destructive influ- 
ence would have destroyed the patient's life within a 
year. Under the steady use of the chloride of aniline 
injections the ulcer has not increased in size, the 
tumor under the jaw is smaller, he takes food as well 
as upon admission, and the entire course of the dis- 
ease has been favorably modified. 

Some decrease in induration, and improvement 
in mobility of the arm, has been noted in an inopera- 
ble recurrent tumor of the right breast, in a case 
which we have had under treatment for six weeks, 
and there seems sufficient ground for persevering in 
its employment. 

Some German observers have reported favorable 
results with this drug, and some have condemned it. 
No authentic records of absolute cure have been pub- 
lished. It seems fair to say, however, that there is 
some ground for the hypothesis that the drug acts 
upon the cell elements of these neoplasms through 
the blood corpuscles. It has no detrimental influ- 
ence upon the general health of the patient, and 
causes no febrile reaction. In other words, its use is 
devoid of all danger. We should continue our ex- 
periments, not without hope of satisfactory results in 
some cases. 



3. PYOKTANIN. 

Professor von Mosetig, of Vienna, published a 
paper in January, 189 1,* reporting his experience with 
pyoktanin, in which he claimed some good results 
from injections of a solution of 1 to 1000. Since that 
time many reports from other observers, both at home 
and abroad, have appeared in medical journals, and 
it is evident that in many instances the growth of the 
tumors has been checked. Some fatal accidents have 
occurred which have been attributed to the drug, so 
that pyoktanin, methylene blue, fuchsin, and the other 
aniline dyes, should be cautiously employed. In the 
New York Hospital experiments with these drugs 
have been abandoned, as well as in the Skin and 
Cancer Hospital. As with the chloride solutions, 
however, so with the others; enough has been secured 
to suggest bright possibilities, and therefore mention 
has been made of these remedies. In no instance, 
however, should such means be employed where a complete 
removal of the diseased tissue can be secured by operative 
procedure. 

In closing this introductory chapter, a classifica- 
tion of cancer from Dr. Snow's work, already referred 
to, is appended, as furnishing the most satisfactory 
arrangement of such diseases thus far published for 
clinical study. As an aid to correct prognosis, all 
tumors should be classified by microscopical exami- 



* Wiener Klinische Wochenschrift, 1891, No. 6. 



— 9 — 

nation after removal, but in regard to treatment no 
delusive pathological report should ever hinder us 
from removing by some means any new growth which 
exhibits even a tendency to malignancy. 

MR. SNOW'S CLASSIFICATION OF CANCER. 
I. 



Alveolar Carcinoma. 

(Derived from glan- 
dular epithelium, 
characterized by 
locular structure). 

II. 

Sarcoma. 

(Origin from connec- 
tive tissue corpus- j 



"(#) Scirrhus. 
^) Encephaloid. {$*£*** 



Round-celled. 



Sub- j Osteoid. 

o • ji 11 j 1. varieties } Melanoid. 
Spindle-celled v v 



Mixed. 



cles. No locular | Glioma. 



(^Myaloid. 



((a) Scaly. 



structure). 

III. 
Epithelioma. 



(Proliferation of epi--^ 
v ., v i • i (£) Columnar, 

thelmm on skin or | v ' 

mucous membrane). [_ 

IV. 

Lymphadenoma. 



j (Sub-variety). 
\ Duct Cancer. 



(Proliferation of lym- 
phatic gland ele- 
ments). 



CHAPTER II. 

DEVELOPMENT OF CANCER FROM NON-MALIG- 
NANT DISEASES— WARTS— MOLES— SEBA- 
CEOUS TUMORS— SIMPLE ULCERS— 
SYPHILITIC ULCERS— PHIMO- 
SIS— UMBILICAL HERNIA. 

Any course of treatment for the cure of cancer is 
successful in proportion to the extent of the disease 
and its location, but to a greater extent to its dura- 
tion from the first appearance of the diseased condi- 
tion. Mr. Jonathan Hutchinson read a paper on the 
" Origin of Tumors," before the British Medical As- 
sociation,* in which he describes what he aptly de- 
signates the " pre-cancerous stage," which probably is 
present in every instance, although often overlooked 
when it happens to be of short duration. If the 
purely local origin of cancer be accepted as the cor- 
rect theory, and Sir James Paget is now the only con- 
spicuous advocate of the old " constitutional origin " 
notion, there is a period in the history of every case 
when the treatment of a disease not truly cancerous 
would insure curative results not hitherto attained. 
With this idea in view a number of cases are here 
noted of non-malignant diseases which have been ob- 
served to be precursors of cancer. 



* Transactions of the British Medical Association, 

1882. 



— II — 

I. WARTS. 

In a paper published in the American Practi- 
tioner for December, 1874,* I gave a brief report of 
a case (No. 1) occurring in a man fifty-five years of 
age, who had a small wart on the right side of the 
nose, about three-quarters of an inch from the angle 
of the eye, which had existed many years, without 
showing any sign of malignancy. Two years before its 
removal it became slightly ulcerated, without any 
known cause, and from that time forward it increased 
gradually in size until at the end of the two years it 
was an unmistakable epithelioma. The cervical 
glands were considerably enlarged. It was removed 
by Marsden's arsenical mucilage, and healed com- 
pletely; but the patient died two years later of cancer 
of the left lung. 

Dr. Thin relates a case of rodent ulcer (epithe- 
lioma), which began four years before its final re- 
moval by operation, as a little wart by the side of the 
nose, the lip of that side being at the same time swol- 
len, on account of inflammation of the eye-tooth. 

It increased in size very slowly, and three years 
after its commencement caustic was applied, which 
seemed to improve it at first; but it soon began to in- 
crease rapidly, and when removed, twelve months 
later, it was an ulcer one-half inch by an inch. 



*Read before the Medical Society of the County of New 
York, June, 1874. 



12 

Microscopical examination of sections through 
the border and surface of the ulcer exhibited the 
usual cell arrangement of rodent ulcer. 

In both of these cases there is no history of 
heredity, and in my own case the history is authentic 
for at least two generations. 

2. MOLES. 

Numerous instances are recorded in which the 
ordinary mole became the seat of cancerous disease. 

Mr. H. Thompson reported the following case at 
a meeting of the London Pathological Society, 
November 6th, i860: 

A lady, aged sixty, was subject from birth to a 
small black mole on the outer side of the left arm. 

It became irritated in hot weather for two sum- 
mers, the second time remaining red and swollen, and 
a melanoid cancer of the size of a large nut resulted, 
which was attended with a large glandular tumor in 
the axilla of the same side. 

It seems that the melanoid variety of cancer 
chooses the neighborhood of a congenital mole, or 
wart, for its development, as in the instance just re- 
lated. 

Mr. Pemberton, of the Birmingham General 
Hospital, in his work on cancer, emphasizes this point, 
and one of his cases is so characteristic that I will 
give it as he relates it: 

" Mrs. M. H., aged forty-five, had several con- 



— 13 — 

genital moles on different parts of the body, one of 
which was near the middle of the forearm. 

"Ulceration began around its edge first, and spread 
therefrom, leaving the mole untouched. At the end 
of four years, an irregular ulcer, two inches in its 
longest diameter, was produced, with borders elevated, 
dark-colored, and indurated. 

" The entire portion was removed by operation 
down to the muscles beneath, and, four years later, 
she remained well. There were no enlarged glands, 
and no history of cancer in the family." 

Other varieties of cancer than the melanoid often 
develop in moles, however, and the same author 
(Pemberton) relates several cases where an irrita- 
tion or slight injury of a congenital mole was followed 
by the encephaloid variety. 

3. — SEBACEOUS TUMORS. 

Sebaceous tumors often result in cancer after 
they have existed for long periods without showing 
any malignant tendency. Sometimes, when middle 
life is reached and the tendency to degenerative 
changes is at its maximum, these growths will begin 
to show signs of activity; some tenderness and pain, 
less mobility, and a thickening of the walls near the 
base of the tumor are often among the first changes 
noted. Ulceration follows later, and the course of 
the disease thenceforth does not differ from that of 
cancer from other causes. 



— 14 — 

Injuries play an important part in other cases; 
and the following case, occurring in the practice of 
Dr. W. W. Crandall, of Wellsville, N, Y., will furnish 
an excellent illustration: 

A man, aged fifty-five, with a wen on the vertex, 
one inch and a half in its longest diameter, which had 
existed for a score of years or more, accidentally struck 
it against a sharp piece of wood, which, if I remember 
rightly, caused slight bleeding. Inflammation of the 
tumor followed, then ulceration and sloughing, which 
was followed, after a few weeks, by cancerous disease 
of the entire border and base of the ulcer. It was 
finally removed by Marsden's method, and the history 
was published in the paper above mentioned. There 
was no family history of cancer. 

Mr. C. Aston Key has reported a case of seba- 
ceous tumor of the scalp * which he removed from the 
scalp of a lady sixty-nine years of age. The top of the 
tumor had sloughed, the margin of the opening 
assumed a cancerous character, and, after the whole 
tumor was removed, a quantity of glairy fluid was 
found at its lower portion, having all the physical 
appearance of colloid. Family history not mentioned. 

4. — SIMPLE ULCERS. 

Simple ulcers occasionally become malignant, 
and two very interesting cases of that kind were 



'* Trans. London Path. Soc. Vol. i, p. 345. 



— i5 — 

tinder treatment at the New York Skin and Cancer 
Hospital, in the service of Dr. Bulkley, in 1882. 

' The first was that of a woman, aged fifty-five, 
who fell down a flight of stairs six years before, re- 
ceiving several cuts about the face by corners of zinc 
covering the steps. All healed except one on the 
right ala nasi, which continued to discharge a little 
watery fluid, and occasionally form a scab over it, 
until within a year and a half, when it began to in- 
crease in size quite rapidly and became nearly two 
square inches in extent, and an unmistakable epithe- 
lioma. A second subsequently developed just below 
the left eye, and entirely distinct from the first ulcer. 
The patient was positive in her statement that no 
cancer had ever occurred in her family. 

The second case was in a man, fifty-seven years 
of age, who received an abrasion of the skin on the 
left leg thirty years before, which healed in a few 
weeks. Ever since that time, however, he had often 
complained of severe itching on the site of the injury, 
and scratching it abraded the skin, and quite a large 
ulcer had often been the result. It had not been 
healed for about six years; and during an acute attack 
of rheumatism, two years before, it began to increase 
in size, and, notwithstanding all the remedies applic- 
able to such cases had been employed for its cure, it 
steadily advanced. The history, upon admission to 
the hospital, was as follows: 

" It is now a deep, irregular ulcer, extending 



— i6 — 

from the ankle nine inches up the leg, its lateral 
diameter being about seven inches. 

" The surface is covered with irregular nodules 
and furrows, of a dark red color, and secreting a con- 
siderable watery fluid. The edges are elevated and 
indurated for nearly an inch from the border, and, 
when compressed firmly, exude a little fluid resem- 
bling pus. The entire ulcer is the seat of an almost 
constant burning pain, described by the patient like 
the sensation of having boiling water poured over it. 

" The man has been a coachman for thirty years, 
and was never sick. Even now his general appear- 
ance indicates good health. There is a bare possi- 
bility of heredity, as one brother died from some 
' sore ' a few years ago." 

An authentic case of cancer developed from an 
innocent ulcer is reported by Mr. Jonathan Hutchin- 
son:* 

" The patient was a woman, aged sixty, who had 
suffered from onychia of the right great toe for about 
eight months. It was said to have been caused by a 
tight shoe. When the remnants of dead nail were 
removed, the matrix and adjacent parts were in an 
inflamed and very irritable state, and resisted all 
efforts to heal them. The base of the ulcer became 
gradually thicker and more swollen, and syphilis 
being suspected, iodide of potassium was adminis- 
tered, but without benefit. 



* Transactions of the London Path. Soc. Vol. viii, p. 404.- 



— 17 — 

" Induration increased and pain became more 
severe, and of a darting, pricking character. 

"Enlarged glands were then discovered about 
the middle of the thigh, just over the large vessels 
where Mr. Hutchinson has several times observed the 
first glandular enlargement in melanosis of the foot. 
The glands of the groin were not affected. The toe 
was removed, and found to be the seat of melanotic 
and medullary cancer." 

At that time the woman had not materially lost 
flesh, and was in good health, although the trouble 
had existed two years. Eight months later she returned 
with a bleeding mass of cancer in the groin, and also 
recurrent disease in the stump of the toe. In this 
case also there was no history of hereditary cancer. 

5. SYPHILITIC ULCERS. 

Syphilis is often the direct cause of cancer, es- 
pecially when the disease appears as a chronic ulcer 
of the tongue. The extreme difficulty of curing these 
syphilitic sores by the ordinary treatment is doubtless 
familiar to every practitioner. 

I have recently seen a syphilitic patient, who had 
been under treatment in hospital for several months 
with ulceration of the tongue, develop an affection of 
the parotid and sublingual glands of the same side, 
which was undoubtedly malignant. 

Walsh does not admit that syphilis is a cause of 



— i8 — 

cancer,* and brings forward arguments against it, the 
chief one being that it is a rare disease among prosti- 
tutes, in whom syphilis is presumably quite common. 
This argument loses its force when the age of that 
class is considered, the average of which is much be- 
low that at which cancer most frequently occurs. 

Scirrhus of the penis has been observed to spring 
from a syphilitic sore, and even Walsh says: "Vener- 
eal ulcers may become complicated by carcinomatous 
deposition and fungate in the same manner as primary 
cancer." The same authority also declares that ven- 
ereal warts may terminate in cancer. 

6. PHIMOSIS. 

Cancer of the penis has been so frequently ob- 
served associated with congenital phimosis that many 
writers have placed it among the causes of the dis- 
ease, and the retention of the natural secretions is 
believed to be the exciting cause. Ten patients out 
of twelve, treated for cancer of the penis by Hey, 
had either congenital or acquired phimosis. 

7. UMBILICAL HERNIA. 

Under this head is given the history of what I 
believe to be a unique case, but one which illustrates 
in a marked degree the result of prolonged local 



* " The Nature and Treatment of Cancer," pp. 155 
and 408. 



— i 9 — 

irritation as a cause of cancer. The case has been 
reported by me to the Medical Society of the county 
of New York.* 

Mrs. B , a widow, aged sixty-seven years, had 

suffered from umbilical hernia fifteen years, but had 
never worn a truss, having always reduced the pro- 
truding intestine easily and frequently, until about a 
year before applying to me for treatment. 

She then began to suffer pain about the umbili- 
cus, and so much soreness that for the three pre- 
ceding months she had not attempted to replace the 
tumor. The pain increased rapidly, and radiated to 
the stomach and pelvic regions, and a marked failure 
in flesh and strength, frequent vomiting, constipation 
alternating with diarrhoea, sleeplessness, and fever 
compelled her to seek advice. 

A monthly metrorrhagia of more or less severity 
had excited no especial surprise in the patient's mind, 
although continued more than twenty-five years be- 
yond the usual period. 

Upon examining the supposed hernia, I found a 
hard, nodulated tumor of a bluish-red color, the sur- 
face of which was slightly ulcerated, in the fold of 
skin at the upper portion. It extended nearly an 
inch beyond the border of the hernial ring, seemed 
quite movable with the skin, and it was a hope shared 
by Dr. A. N. Brockway, who saw the case with me, 



* N. Y. Medical Record, Oct. 12, 1889. 



20 

that the disease had not invaded the peritoneal cavity. 
An operation was advised, and after the patient was 
etherized, so that a thorough examination of the base 
of the tumor could be made, it was found to invade 
the ring, and all hope of a slight operation was 
abandoned. An elliptical incision being made, the 
tumor was dissected out as far as the ring, and then 
carefully examined for any intestinal contents. It 
evidently contained no gut, and was removed in 
order to facilitate examination of the parts beneath. 
The sac contained some omentum which was not 
diseased. The subperitoneal tissue was infiltrated 
as far as the finger could reach. It was thoroughly 
removed, and the wound then closed as after ovari- 
otomy. 

The patient rallied well after the operation, but 
died sixty hours afterward, apparently from shock, no 
peritonitis having developed. 

It should be stated that an examination, while 
the patient was under ether, revealed a much enlarged 
cervix, but no sign of cancer, although the body of 
the uterus was so large as to suggest the possibility of 
its being the seat of malignant disease. 

The first section from the apex of the tumor 
proved to be a large, round-celled, alveolar sarcoma. 

The second section was from a portion of the 
base of the tumor just outside the neck of the sac, and 
was of especial interest on account of the gland-tissue 
which it contained, the origin of which was believed 
to be embryonic. 



21 



Dr. George T. Elliot has very kindly furnished 
me the following description of this rare form of 
tumor: 

" The portions of the tumor removed from the 
umbilical region, which were received by me for micro- 
scopical examination, were hardened in alcohol, and 
the sections were stained with borax-carmin and pyro- 
gallic acid and iron. 

" It was not difficult to determine the nature of 
the growth, since portions of the sections were found 
composed of small spindle-shaped cells, with here 
and there a few large round cells, while in others 
these latter were arranged in more or less large 
alveoli formed by the bundles of connective tissue. 
In many of these alveoli, capillary blood-vessels, 
which were abundant throughout the tissue, pene- 
trated in between the cells contained in them. From 
these features it was evident that the new-growth was 
a sarcoma composed of mixed cells, spindle-shaped 
and round. 

" In addition to the sarcomatous tissue, however, 
there were found other histological elements which 
greatly increased the interest taken in the specimen. 
Distributed throughout the sections, more or less 
abundantly, glandular tissue was found, which was in 
every way identical with the glands of Lieberkuhn 
existing in the small intestines. 

" The glands were composed of abasement mem- 
brane and columnar epithelium, and they were separ- 



22 



ated one from another by more or less connective 
or sarcomatous tissue. Some were unchanged, others 
were hyperplastic, while still others had 'undergone 
cystic degeneration. 




A — Glandular tissue more or less surrounded by small spindle-celled 
(b) sarcomatous tissue, and large round sarcoma-cell. 

"The tissue between them was more or less 
infiltrated with small round infiltration-cells. 

" The presence of the intestinal glandular tissue 
in this tumor is not an extraordinary fact, but yet one 



— 23 — 

which is rarely met with. Growths of this class occur 
at the umbilicus, and are known under the name of 
enteroteratoma. To understand the occurrence of 
these growths, it must be remembered that in fcetal 
life the ductus omphalo-mesentericus is prolonged 
into the umbilical cord, but normally disappears 
before birth. Abnormally, however, it may persist 




Alveolar large round cell sarcoma. 

at its apex. 



Section through tumor 



and develop into a tube resembling intestine, and 
either form a congenital diverticulum of the small 
intestines, or more rarely, if this development has 
occurred in the portion of the duct situated just in 
front of the navel, there remains a small tumor after 
the falling off of the severed umbilical cord. 

"This seems to be the only way in which the 
presence of the intestinal glands in the tumor could 



— 24 — 

be explained; that is, that the original growth was an 
enteroteratoma to which no attention had been paid, 
but which persisted and finally underwent sarcoma- 
tous degeneration. It seems, however, remarkable 
that it should have persisted so long before under- 
going change." 



CHAPTER III. 

DEVELOPMENT OF CANCER FROM NON-MALIG 

NANT DISEASES— PSORIASIS— ICHTHYOSIS 

OF THE TONGUE— LEUCOPLAKIA— 

ECZEMA, OR PAGET'S DISEASE 

OF THE NIPPLE— REMARKS 

ON THE/€TIOLOGYOF 

CANCER. 

8. PSORIASIS. 

At least four cases are now on record where epi- 
thelioma has developed on a psoriatic base — two by 
Dr. White in 1885, one by Cartay in 1878, and one by 
Hebra. 

In White's and Hebra's cases there was a transi- 
tion of warty growth of the plaques, a form to which 
the name of psoriasis verrucosa is given. These cases, 
while showing that psoriasis is not simply a parakera- 
tosis, but also of inflammatory nature, renders a prog- 
nosis of much greater moment in cases where any 
appearance of warty growth is manifested. 

Under this head may be mentioned the so-called 
ichthyosis of the tongue, which in a certain proportion 
of cases has been observed to terminate in epithelioma 
or carcinoma. Without undertaking any criticism or 
justification of this application of the term ichthyosis, 
I will simply say that reference is made to such cases 
as Mr. Hulke, of the Middlesex Hospital, described 



— 26 — 

before the Clinical Society of London a few years ago 
under that name. In one case, which terminated in 
fatal carcinoma, there was an area of disease over 
which the papillae were greatly hypertrophied; the 
surface of that part of the dorsum was warty on ac- 
count of the overgrowth of the papillae, which, instead 
of preserving their natural consistence, were much 
harder than natural and sometimes quite " horny." 
There were three such patches, which were removed by 
operation, but the cancerous disease developed from 
smaller patches which were not removed, and not in 
the cicatrices, which remained healthy. 

Leucoma, or leucoplakia, sometimes terminates 
in malignant disease. I have recently removed by 
operation an epithelioma of the lower lip in a man of 
forty (who was not a smoker), which began as a leu- 
coplakia of the inside and border of the lip. 

9. ECZEMA, OR PAGET'S DISEASE OF THE NIPPLE. 

The development of cancer of the breast, when a 
chronic eczema of the nipple had existed for a long 
time, has naturally led to the inference that they 
stood in the relation of cause and effect. 

Mr Henry Morris, of the Middlesex Hospital, 
reported two cases, in one of which the eruption 
existed four years, and in the other six, before cancer 
was suspected. Both patients died of secondary 
cancer. 

Mr. Thomas W. Nunn, in his recent admirable 



— 27 — 

work on " Cancer of the Breast," refers to Mr. Morris* 
cases in connection with one observed by himself, and 
also furnishes the conclusions arrived at by Mr. H. T. 
Butlin, in a paper on the same subject. 

I take the liberty of copying Mr. Butlin's propo- 
sitions as Mr. Nunn gives them: 

i. That a certain relation existed between the 
eczema of the nipple and the areola and the carcin- 
oma of the breast. 

2. That one of the first effects of the eczema 
was to produce proliferation of the mucous layer of 
the epidermis of the parts affected. 

3. That in time the epithelium lining the galac- 
tophorous ducts became affected in like manner. 

4. That the disease, traveling along the large 
ducts, reached the smaller ducts and acini, which 
became dilated and filled with proliferating epithe- 
lium, which was at length, so to speak, discharged 
into the surrounding tissues. 

5. That the carcinoma thus formed was there- 
fore essentially a disease of epithelium. 

Whether we accept this theory of production, or 
the opposing one of Dr. Thin — that, instead of a cell 
proliferation, the growth is the result of a special 
development of colorless blood corpuscles— the fact 
that cancer of the breast does result from eczema of 
the nipple and areola seems to be pretty well estab- 
lished. 



*Med. Chirurg. Trans., Vol. LXIII, p. 37. 



— 28 — 

This disease is known in literature as Paget's 
Disease of the Nipple, because it was first described 
by Sir James Paget.* (See illustration opposite p. 32.) 

His report was based upon fourteen cases, in 
patients varying from 40 to 60 years of age. The 
nipple, or areola, or both, in some instances, were 
observed to be the seat of an intensely red, very 
granular, raw surface, discharging a copious, clear, 
yellowish, viscid fluid, and attended with a tingling, 
itching or burning sensation. 

In some of the cases the eruption was dry like 
psoriasis, while in others only the ordinary characters 
of chronic eczema were presented. 

Dr. S. W. Gross accepts the view of Sir James Pa- 
get that these cases are simple eczema in the beginning, 
and from the long-continued irritation produce can- 
cer, just as the ichthyosis of the tongue has been shown 
to produce epithelioma of that organ. 

This view is supported by the authentic reports 
of cure of such an eruption of the nipple by Busch, 
and also by Dr. Gross, who successfully treated such 
a chronic eczema by a lotion composed of equal parts 
of glycerin and laudanum. 

I have had two cases in which cancer developed, 
the diagnosis of which was verified by the microscope 
after amputation of the breast. The eczema involved 
only one nipple. 



Report of St. Bartholomew Hospital, Vol. X, p. 87. 



— 2 9 — 

Another case was cured by resorcin ointment 
and a general tonic treatment, although the disease 
had persisted for eighteen months, which proves that 
Mr. Lawson's advice to excise any breast where 
eczema of the nipple resists treatment for one year is 
not to be implicitly followed in all cases. No recur- 
rence has occurred in my cases after three years, and 
it seems to be true that this paricular variety of can- 
cer of the breast is less malignant than the usual form 
of the disease. 

Numerous cases similar to those here presented 
are recorded, but enough {iave been cited, I believe, 
to establish beyond question that cancer is not always 
the outgrowth of malignancy. In other words, in the 
cases here recorded there was a pre-cancerous stage, 
when the patient could have been cured by removing 
a simple subaceous tumor or a wart — by a judicious 
management of an eczema of the nipple, or a lacer- 
ated wound of the face. 

Any long continued irritation, such as a broken 
tooth upon the lip or tongue, inflamed haemorrhoids, 
or chronic inflammation in a lacerated cervix uteri, 
will very often cause cancer. 

In such local causes are to be found the most im- 
portant factors in the aetiology of malignant diseases. 
Heredity plays so insignificant a part in causation 
that it may be left out of future consideration. Less 
than five per cent, of my five hundred cases gave any 
family history of cancer whatever. In most instances 



— 3° — 

where two or more cases have occurred in a family it 
is simply a coincidence, just as it is where two or 
more near relatives die of pneumonia. 

Until the pathologist discovers a cancer bacillus, 
we must continue to affirm that the causes we have 
referred to in this and the preceding chapter are suf- 
ficient to produce the disease in such organs as the 
age and general condition of the patient may have 
rendered susceptible to such epithelial degenerations. 

Before leaving this subject permit me to enter a 
strong protest against the common practice of trying 
the effect of mild caustics, such as nitrate of silver, 
pyrogallic acid, resorcin, and many others, upon these 
malignant diseases. Nearly always such applications 
stimulate the progress of the disease, and very seldom 
-do any good whatever. This is eminently true of the 
galvanic current as applied to the surface of tumors. 

A scirrhous tumor of the breast, which the physi- 
cian in charge permitted me to examine recently, had 
made such remarkably rapid progress that some 
special cause was sought for, and found, as I believe, 
in the mild and frequently repeated galvanization of 
the tumor by an over-zealous advocate of that 
remedy. 



CHAPTER IV. 

REMARKS ON DIAGNOSIS— CLINICAL FEATURES 
SUFFICIENT— MICROSCOPICAL EXAMINA- 
TION VALUABLE FOR PROGNOSIS— 
IN DOUBTFUL CASES TREAT 
THE DISEASE AS 
CANCER. 

Success or failure in the treatment of cancer de- 
pends largely upon an early diagnosis. Every sur- 
geon who sees many patients is familiar with the dis- 
heartening recital of the patient that she showed the 
tumor to her family physician months ago, who ad- 
vised the use of some ointment or other local applica- 
tion, and told her to inform him if it did not disap- 
pear. I cannot hold the physician blameless who 
thus calms a patient's anxiety by what he knows, or 
should know, to be utterly false advice, for which his 
unfortunate patient often pays with her life 

The references already made to the diseases 
which are often the exciting cause of cancer should 
emphasize the necessity for a most careful and consci- 
entious study of any and every new growth in every 
case, and especially in those where the patient has 
reached forty years of age. 1 have now under treat- 
ment the most malignant disease of the orbit I have 
ever seen, and the boy is only nine years old; but 
fortunately cancer in early life is a rare affection. It 



— 32 — 
is pre-eminently a disease of middle life. This is 
especially true of cancer of the female breast, which, 
from its frequency, may be taken as the type of the 
disease for purposes of study. 

Dr. Willard Parker's table of 359 cases of cancer 
of the breast* is exceedingly valuable as showing the 
age at which the development is most frequent. Of 
his cases the disease commenced — 
Between 25 and 30 years, in 5 cases 



30 ' 


' 35 " 


35 ' 


40 " 


40 ' 


' 45 " 


45 * 


' 50 " 


50 ' 


' 55 " 


55 ' 


« 60 " 


60 ' 


« 65 " 


'■ 65 ' 


' 70 " 


70 ' 


« 80 " 



23 

54 
78 
80 

57 
3* 
12 

14 

5 



359 



It thus appears that 246, qr more than 68 per 
cent, of the entire number, began between the ages of 
40 and 60, while only 2>2 y or 22 per cent., were be- 
tween 25 and 40, and of these 5 cases only were under 
30 years of age. My own tables and all others 
show about the same proportions, so that we may 
place the age of the patient among the most import- 
ant elements of diagnosis from a clinical standpoint. 
After the menopause has been thoroughly passed, 



*A Study of Cancer, p. 8. 




PAGET'S DISEASE OF THE NIPPLE. 



— 33 — 

every tumor of the breast is probably cancer. In the 
face of this fact, a patient, 54 years of age, applied to 
me for treatment with a large scirrhus tumor of the 
right breast, for which an experienced physician had 
prescribed an application of tincture of iodine, and 
expressed the opinion that it was an inflamed milk 
duct ! 

The next important step in arriving at a diagno- 
sis is the study of the aetiology of the growth. Has it 
developed upon any of the pre-cancerous diseases 
already alluded to ? Is there any history of injury to 
the part affected, the effects of which have never 
quite disappeared ? Has there been a history of pro- 
longed local irritation, such as the sharp edge of a 
tooth against the tongue, for example ? If these 
questions are answered in the affirmative, the disease 
is probably cancerous. The question of heredity is 
of such slight importance that it need only be asked 
for the purpose of confirming our judgment that it 
plays a most insignificant part in the causation of 
cancer. 

In the next place, the location of the growth is 
an important aid in diagnosis. There are several 
favorite locations for cancer besides the mammary 
gland. We should look with especial care to disease 
in the lower lip of a man, or to a scaly patch on the 
temple, or on the side of the nose, in the neighbor- 
hood of the canthus, or on the border of the tongue 
about midway between the tip and the root. 

3 DDD 



— 34 — 

The symptom of pain is so variable as to be of 
little aid in diagnosis, even in cancer of the breast, in 
which cases it is often very slight or entirely absent. 

The sense of touch, when educated by experi- 
ence, is the almost infallible diagnostician of cancer. 
A man may discard every other means, and yet cor- 
rectly diagnosticate cancer with his index finger 
ninety-nine times out of a hundred. It is more un- 
erring than the microscope. This leads me to say of 
the microscopical examination of malignant growths 
that its chief value to us as practitioners consists in 
its invaluable aid to a correct prognosis. It is un- 
necessary and often impossible to secure a slide for 
examination until after operation, but then it becomes 
of the greatest interest to know whether the structure 
of the tumor is of such a nature as to render probable 
a speedy recurrence or a fatal metastasis. If the 
microscopist finally succeeds in discovering a cancer 
bacillus as the real cause of these malignant diseases, 
he will have added the most important link to the 
long chain of his valuable discoveries. But we should 
never be dissuaded from eradicating a suspicious 
growth because we may have had a section examined 
which did not show the microscopical characters of 
carcinoma, sarcoma, or epithelioma. Mr. Butlin* cor- 
roborates these views regarding the value of the mi- 
croscope in the following words: 

" It is not always easy to classify a tumor, even 



* Sarcoma and Carcinoma, p. 9. 



— 35 — 
though its origin and microscopic structure have been 
carefully observed. The difference in structure be- 
tween some adenomas and some carcinomas, between 
some fibromas or chondromas and some sarcomas, 
and between the products of some inflammations and 
some sarcomas, is so very minute, if, indeed, there is a 
difference, that it is impossible to discover it." 

I do not wish to be understood as discrediting in 
any degree the results or value of microscopical ex- 
aminations in cancer cases, but to forcibly impress 
upon the reader the fact that the practitioner must 
depend upon the clinical features, history, and course 
of the disease chiefly, especially if the early diagnosis 
of the disease is to be reached and the chances of 
cure thereby rendered most certain. 

I have recently had an interesting experience 
with a patient for whom we had removed the right 
breast and axillary contents for carcinoma and, sub- 
sequently, six recurrent growths in or near the cicatrix 
on the chest. At the last operation a small exostosis 
of the fifth rib was removed (a mistaken procedure, I 
now believe), and there was great difficulty in healing 
the wound. After three months, it was decided to 
remove this stubborn sore, and it was handed to the 
microscopist, who reported it to be " simple cicatricial 
tissue." As there was no appearance of any other 
disease, the axilla having remained free since the first 
operation three years before, and in view of the fact 
that the patient's general condition was good, we at 



- Sc- 
once, decided that the prognosis was favorable. The 
sequel proved all our deductions to be incorrect, for 
in three months there was a large tumor of the spleen, 
and recurrence also at the very point where this 
" simple cicatricial tissue " had been found by the 
microscopist. What other course, then, is to be fol- 
lowed in cases where the diagnosis is uncertain? The 
question has been partly answered in the preceding 
chapters, where we advised the removal of all those 
non-malignant diseases which have been shown to 
develop into cancer. 

All the clinical elements of diagnosis, and the 
histological characters, should be studied, if possible, 
and then, if there remains any doubt, treat it as a 
cancer. The question as to whether in this way a 
breast is sometimes removed which might have been 
saved must be answered in the affirmative. The re- 
moval of a benign tumor, however, is accomplished 
with such slight risk, and the probability is so great 
that such a growth will become a source of the fatal 
chronic irritation of the tissues which produces cancer, 
that the proper treatment has been employed to give 
the greatest possible security to the patient. A doubt- 
ful or erroneous diagnosis, then, has no disadvantages 
as far as the patient is concerned in this direction, 
while to wait for some unmistakable feature of cancer 
to be manifested, before proceeding to treat it radi- 
cally, is fraught with extreme danger. 



CHAPTER V. 

EPITHELIOMA OF THE SKIN— TREATMENT BY 

MILD CAUTERIZATION— ESCHAROTICS— 

LACTIC ACID PASTE — JENNINGS' 

POTASH AND COCAINE PASTE— 

MARSDEN'S PASTE— 

BOUGARD'S 

PASTE. 

The most important fact connected with the class 
of cases under consideration is that ninety per cent, 
of them are curable if early and efficient treatment be 
adopted. Cancer in the popular mind has always 
been regarded as an incurable disease, and yet, accord- 
ing to Marsden's tables,* compiled from the records 
of over six thousand cases of cancer treated in the 
London Cancer Hospital, over two thousand, or one- 
third of the entire number, were surface or epithelial 
cancer. It is a disease which seldom appears before 
middle life, when the vital forces are on the decline, 
and at a period when degeneration of other organs 
besides the skin is frequently observed. In these 
cases, then, age is an important factor in aetiology. 
Reference has already been made to several non- 
malignant diseases which tend to become cancerous, 



*A New and Successful Mode of Treating Certain 
Forms of Cancer, by Alexander Marsden, M. D. 



- 3 8 - 

and long continued local irritation is often the excit- 
ing cause. Thus an epithelioma finally developed 
upon the side of the nose in one of my patients at 
the point where the eye-glasses had rested for many 
years. 

It occurs with far greater frequency in men than 
in women, Marsden's table making the ratio nearly 
three to one. Nearly the same proportion is main- 
tained among my own cases. There are certain loca- 
tions which may be termed the point of election for 
the disease, by far the greater number being upon the 
side of the nose, a little before the inner canthus, and 
upon the temple. 

The following description applies to most cases 
in their early stages. 

The patient first notices a small crust, which 
covers an area of skin perhaps an eighth of an inch 
in diameter. It is easily removed, but is soon repro- 
duced. After this process has been often repeated, 
the surface under the scab is found to be raw, and 
bleeds a little when the crust is first removed. After 
a variable period, active ulceration begins in the cen- 
tral portion, the borders become slightly elevated 
and indurated. Then a section through this border 
will show the usual arrangement of so-called " cell 
nests " under the microscope, and a disease exists 
which will never heal unless its most complete de- 
struction is in some way secured. Its course is often 
slow, and it is not unusual to find a patient who has 



— 39 — 
suffered with an epithelioma of the skin for ten or 
fifteen years. The rapidity of its course, however, 
depends, to a large extent, upon the part of the body 
attacked, being slow if in those parts of the face where 
there is but little subcutaneous tissue, like the malar 
region, or upon the scalp, while in the labia majora its 
course is rapid, and difficult to cure in consequence. 
Another cause of rapid development is the injudicious 
employment of comparatively mild caustics. 

By the term mild cauterization I mean all caustic 
applications of whatever kind which aim at a gradual 
destruction of the diseased tissue. A few cases will 
illustrate my meaning. A young man of thirty years 
consulted a physician about one year ago for a 
"cracked" lip, which had troubled him two or three 
months. During the next six months eighty applica- 
tions were made to the lip, so the patient says, of a 
caustic answering to the description of nitrate of 
silver. The result is the entire lower lip cancerous, 
an enormous tumor on the left side of the face and 
inferior maxillary region, which has ulcerated in 
several places, and the "cancer cachexia" of the 
older writers indicates an early fatal termination. 
This very unusual glandular infection can only be 
accounted for by the fact, as I believe, that the 
repeated applications acted in the same manner as 
the local irritation which is so often the exciting cause 
of the primary disease. 

Nitrate of silver is one of the most frequent of 



— 4o — 

mild applications and also one of the most injurious. 
It is probable that no epithelioma of the tongue ever 
escaped an application of this remedy, and it is equally 
certain that no case was ever benefited thereby. 

Pyrogallol and resorcin, both of which have been 
highly recommended by Unna and others, have been 
extensively employed, and, as far as my observation 
of many cases is concerned, I have no hesitation in 
saying they should never be employed in the treat- 
ment of epithelioma of the skin. 

It may be stated that no method of treatment 
should be applied which aims at anything short of 
complete destruction and removal of all diseased 
tissue. The only possible exceptions to this rule are 
occasional instances in which a tongue may be re- 
moved to allow of increased facility in feeding; a 
tumor near the eye, where the sight may be preserved 
for a time after the one eye has been destroyed, or 
where a pendulous or ulcerating tumor(as of the breast) 
may be rendered less painful or offensive for the time 
being by the removal of a portion of it. Such are 
palliative measures which may be justifiable, although 
life is not usually even prolonged thereby. 

Cutaneous cancer is usually treated more satis- 
factorily by escharotics than by any other method, 
and for various reasons. The patients are usually 
past middle age, often far advanced in years, and 
as a class not good subjects for etherization. The 
antipathy to a surgical operation often leads them to 



— 41 — 

delay treatment until the pre-cancerous stage, as Mr. 
Jonathan Hutchinson has termed it, has been followed 
by active malignant characteristics. You can always 
quite readily persuade them to have a plaster applied. 
The disease can be thoroughly destroyed by the 
caustic plasters, for they will all act sufficiently upon 
■diseased tissue in so much less time than upon healthy 
skin that there is almost an excuse for the fallacy that 
they exercise a positive power of selection. The re- 
sulting cicatrix, when the deep subcutaneous tissues 
.are not involved, is a very smooth, white, and in every 
way healthy one, far less conspicuous than after re- 
moval by operation. Recurrence is no more frequent 
than after operation, but experience has convinced 
me that the claim of the cancer quacks that recurrence 
after caustic is less frequent than after removal by the 
knife is positively groundless. The only cases in 
which an operation should be preferred to a caustic are 
those involving the mucous surface of the lip, the eye- 
lids, and all others which have involved a large sur- 
face, so that dangerous poisoning might result from 
absorption. 

The choice of a proper escharotic is of consider- 
ble importance. If the disease be a very small warty 
growth, the potassa and cocaine paste of Mr. Jennings 
is a good one.* The formula is as follows: 



* Cancer and its Complications, Chas. Egerton Jen- 
nings, F. R. C. S., p. 66. 



— 4 2 — 
Jennings' Paste. 

§ Cocaine hydrochlorat 2 . 

Potass, caustici 12 . 

Ung. petrolat 6 . 

M. 

After cleansing the surface and applying a solu- 
tion of Cocaine, this paste is to be rubbed into the 
growth with a small wooden spatula. 

Acetic acid must be at hand to limit its action as 
soon as desired. Where the disease is that form of 
epithelioma called rodent ulcer by some, and Jacob's 
ulcer by other authors, with little or no induration of 
the borders, a paste composed of lactic acid and 
salicic acid, in such proportion as to make a thick 
paste, is effectual in destroying the diseased surface. 
It has one advantage over others, in that it is not 
poisonous, and can be spread over a large surface.. 
It is less active than the others, and requires frequent 
repetition. I now very seldom employ it. The actual 
cautery is too painful, and patients are much fright- 
ened by the very appearance of the doctor armed 
with a red-hot instrument. 

In 1874, in a paper read before the Medical So- 
ciety of the County of New York, I described the 
method, then new, of applying an arsenical paste as 
recommended by Dr. Alexander Marsden, Surgeon- 
in-Chief of the London Cancer Hospital, and gave 
histories of twelve cases successfully treated by it. 
Since that time I have employed the same paste in 



— 43 — 

over one hundred cases. It is satisfactory in the 
main, and has become a well-recognized remedy 
throughout this country. In some cases the reaction 
is very great and the pain very severe, although less 
is experienced if cocaine is mixed with it. 

Mars den s Paste. 

"Sf Acid arsenioni 4. 

Pulv. acaciae 2. 

M. 

This is to be made into a paste too thick to run r 
by very carefully adding cold water, or instead of the 
powdered acacia, the mucilage may be employed. 

It is then applied to only one square inch of the 
ulcer, covered with cotton to absorb any superfluous 
paste, and left on until swelling occurs around it with 
heat and redness, when it is removed, and a line of 
demarcation usually surrounds the surface cauterized. 
From one to three days are required to produce the 
desired effect. Warm poultices are then applied until 
the slough separates (usually about a week), when, if 
the disease is all removed, the healing process pro- 
ceeds as in an ordinary granulating sore. The same 
process is to be repeated until the disease is all re- 
moved. Marsden insists that no cancer of more than 
four square inches in extent should be thus treated, 
and only one square inch at a time, and the case very 
carefully watched. The surgeons of the London 
Hospital inform me that even Marsden himself seldom 



— 44 — 

employs the paste at present. They have substituted 
an application called Bougard's paste, after the Bel- 
gian surgeon, who first published the formula in his 
work on caustics.* The author brought it forward 
as a cure for mammary cancer, but as such, in my 
judgment, it is open to the same objection as all 
other caustics; but in cutaneous and lip cases, in 
fact in all surface epitheliomata where any escharotic 
is admissible, this is by all odds the best we have at 
present. It is less painful than Marsden's, forms a 
more dry and friable slough, can be safely applied to 
a larger surface, and can always be prepared and 
ready for instant use, for in a covered jar it will keep 
for many months. With both pastes the surface must 
be denuded, if necessary, by caustic potash to render 
the action prompt and effective in the shortest pos- 
sible time. 

Bougard's formula is as follows: 

Wheat flour 60. 

Starch . 60. 

Arsenic . . 1 . 

Cinnabar 5 . 

Sal-ammonia 5 . 

Corrosive sublimate o. 50 

Solution of chloride of zinc at 52 ..... 245 . 

The first six substances are separately ground 
and reduced to fine powder. They are then mixed in 
a mortar of glass or china, and the solution of chlor- 

; ' ' • 

* Etudes sur le Cancer (Brussels, 1882). 



— 45 — 

ide of zinc is slowly poured in, while the contents are 
kept rapidly moved with the pestle so that no lumps 
shall be formed. A thick layer of this is spread on 
cotton and left in position twenty-four hours, and then 
managed in every way as Marsden's paste. Few cases 
require a second application. The ulcer may be 
dressed with balsam of Peru ointment of varying 
strengths, according to the stimulation required, and 
all exuberant granulations are to be kept in check by 
the usual methods. 

An excellent dressing, instead of the Peruvian 
balsam, is a five or ten-per-cent. aristol ointment, 
with vaseline as a base. However, this after-treat- 
ment is not of vital importance, except in one respect, 
viz.: healing under a scab in ca7icer cases can never be 
trusted. 



CHAPTER VI. 

EPITHELIOMA OF THE EYELIDS AND OF THE 
LOWER LIP — TREATMENT BY CAUSTICS 
AND BY OPERATION-EPITHELIOMA OF 
THE TONGUE— KOCHER'S AND 
WHITEHEAD'S OPERATIONS- 
PROGNOSIS ALWAYS UN- 
FAVORABLE. 

Epithelioma of the eyelid finally involves, in a 
large proportion of cases, the eye itself. The disease 
usually attacks the lower lid, and a warty growth is 
frequently the first manifestation. Two years ago 
a patient now under treatment first noticed en- 
largement of a small congenital wart on the right 
lower lid, a little outside of the middle. She 
squeezed it between the thumb and finger, and some 
bloody fluid escaped, but no pus. The growth then 
slightly ulcerated, and very gradually an induration 
has crept along the outer border of the lid until now 
it has reached the canthus, and the thickening ex- 
tends into the body of the lid nearly an eighth of an 
inch. Some pressure upon the eyeball has resulted, 
and the conjunctiva is streaked with congested ves- 
sels, but is apparently free from malignant infection. 
The usual mistake of calling the disease lupus was 
repeated in this case, and the repeated application 
of nitrate of silver has stimulated the growth con- 



— 47 — 

• 

siderably. I doubt whether the disease began as 
lupus, but it may have done so. I have seen 
that transformation occur, but a microscopical sec- 
tion of the growth now shows all the characters of 
epithelial cancer. The treatment of this particular 
case will spare the eye, so long as it appears to be 
healthy. The diseased portion will be excised by 
scissors, the patient being etherized. Then the gap 
in the lid will be filled by a flap from the neighbor- 
hood, the parts all being carefully secured in position 
with horse-hair sutures, and the incision painted with 
aristol collodion (i — 30). The eye will then be se- 
curely bandaged, and the dressing left undisturbed 
several days, unless there should be some local or 
constitutional symptoms referable to the field of oper- 
ation. This typical case is here given, with the treat- 
ment, to emphasize the fact that all cancer of the eye- 
lid, whether of small extent or of the most serious 
character, should be removed at once, and only by 
operation. Caustics of every description are contra- 
indicated in this region, for they are not only ineffi- 
cient, but positively harmful. During the past three 
weeks I have extirpated the eye for two patients, re- 
moving the entire upper and lower lids in both cases, 
for epithelioma which has been treated over two years 
with the utmost thoroughness, by curetting and caus- 
tics of various kinds, but the progress of the malady 
has scarcely been impeded thereby, and the eyesight 
in each case has been nearly destroyed. It should 



- 4 8 - 

be stated that, when not more than one-third of the 
border of the lid is involved, it can often be success- 
fully removed by cutting away an elliptical piece 
without a plastic operation, as it will heal kindly by 
granulation. In case undue pressure is caused by 
the cicatrix, a simple canthoplasty will relieve it. 

One word more regarding extirpation for cancer. 
It is not a dangerous operation, and it is frequently 
successful in effecting a permanent cure. All the 
contents of the orbit should be removed with curved 
scissors, and the cavity then closely packed with 
moist aristol gauze and tightly bandaged, to prevent 
haemorrhage. It is likely to be a bloody operation,, 
but it is difficult to take up the vessels, so I hasten 
through the operation and apply the dressings as 
quickly as possible. Several patients have had no 
recurrence after this operation, although performed 
from five to seven years ago. Their ages ranged 
from sixty to eighty-one years. 

EPITHELIOMA OF THE LOWER LIP. 

Nearly twelve per cent, of my cases have been 
cancer of the lower lip, and all were men, with one 
exception. The oldest patient was eighty-two and 
•the youngest twenty-six, the average age being fifty- 
five, so that the disease is pre-eminently one of old 
age. Only twenty-one per cent, were smokers, so 
that the use of the pipe plays a small part in the aeti- 
ology. Any ulcer, fissure, or scab on the lower lip of 



— 49 — 

an old man is probably cancerous if it persists for any 
length of time, especially when resisting treatment by 
ordinary remedies. Fortunately, nearly all begin in or 
near the median line and outside of the lip. For that 
reason, when the disease is small, it may be best 
treated with caustics, Bougard's paste being the most 
satisfactory. Its action is prompt, twenty-four hours 
sufficing to destroy the growth, and under poultices, 
applied in a muslin pouch, held in position by tapes 
tied around the neck, the slough will separate in 
about four days, the resulting cicatrix being imper- 
ceptible. The plaster is held in position by collodion 
and the patient cautioned against touching it with the 
tongue, for fear of poisoning. The case should be care- 
fully watched while the paste is on the lip. 

When the cancer has attacked the entire thick- 
ness of the lip, and has passed below the vermilion 
border, excision is the only remedy. Any projecting 
tooth should be removed, and, with the lip firmly held 
on both sides by the thumb and finger of an assistant, 
a free removal is made by two curved incisions, thus: 
(J instead of the usual V incision, which has always 
been recommended. The advantage of the curved 
incision consists in a more even distribution of the 
traction caused by the sutures, and the occasional 
difficulty of securing perfect union at the border after 
the V incision is thereby, avoided. The edges are 
adjusted and stitched with interrupted horse-hair 
sutures, the incision being then well painted with the 

4 DDD 



- 5° — 

aristol collodion and left undisturbed until union is 
complete. I seldom apply a bandage or any other 
dressing, simply cautioning the patient against open- 
ing the mouth or in any way stretching the tissues of 
the lip. The prognosis is excellent irr these cases, 
unless treatment is delayed, in which case it becomes 
exceedingly grave, especially if the angle of the 
mouth is involved, or the cervical glands affected. 
Early diagnosis and prompt removal mean success, 
while the reverse invites probable failure. 

EPITHELIOMA OF THE TONGUE. 

I have never seen a cancer of the tongue of any 
but the epithelial type. At the same time it is true 
that a sarcoma is very rarely found here, such as Dr. 
Jacobi's case, in an infant the day after, birth, which 
was removed and examined with the microscope a 
couple of months afterwards.* The mere fact that a 
disease of the tongue of a cancerous character ap- 
pears very rarely in a young person under thirty ren- 
ders it probable that the disease is epithelioma, if the 
patient has passed that age. There is no question of 
the correctness of the rule that sarcoma is a disease 
of early life, and that epithelioma and carcinoma be- 
long to the later period, but there are occasional ex- 
ceptions in both cases. 

The tongue is not only subject to epithelial can- 
cer, but in the frequency with which it suffers there- 



* American Journal of Obstetrics, 1870. 



— 5' — 
from it has but one rival, that being the uterus. Mr. 
Jessett has analyzed 2,227 cases, occurring in the 
London Cancer Hospital during the ten years ending 
in 1881, of which 8.5 per cent, were the tongue, 12.3 
per cent, in the uterus, and 31.3 per cent, in the female 
breast. From my 534 cases it appears that 6.3 per 
cent, were in the tongue, 4.3 per cent, in the uterus, 
and 26.5 per cent, in the mamma. There is an evident 
explanation of the difference between my percentages 
and Mr. Jessett's, Mr. Henry Morris', Sir James 
Paget's, and others, which shows how misleading in- 
dividual statistics may be, in fact usually are, in regard 
to frequency of diseases of special organs. This ex- 
planation is the fact that patients apply to specialists 
for advice, and thus it happens that the gynaecologist 
finds a great preponderance of cancer in the uterus, 
almost none of the tongue, and comparatively few of 
the breast, because tumor cases occurring in the 
breast drift to the general surgeon. Those of us who 
are connected with the New York Skin and Cancer 
- Hospital see an undue proportion of epithelioma of 
the skin. Jessett's tables, made up from the general 
records of the Cancer Hospital, are more nearly cor- 
rect in regard to this point than any individual case 
records. 

Cancer of the tongue, like epithelioma of the lip, 
is a disease of men, the exceptions being very few, 
only three of my thirty-four cases being women. At 
the risk of repeating to some extent what has already 



— 52 — 

been said regarding setiology, the following table of 
causes may be profitably considered: 

Age. 
Sex. 

Leucoma. 
Psoriasis. 
Predisposing Causes. ....-{ Ichthyosis, 

Syphilis. 
Spirit-drinking. 
Smoking. 
Rough eating. 

f Caustics. 
| Bad teeth. 

Exciting Causes -{ Dental plates. 

j Irritation of pipe. 
[ Salivary calculi. 

Syphilis plays an important part among the pre- 
disposing causes of cancer of the tongue. Its influ- 
ence, however, is an indirect one. A gumma appears 
on the tongue, or a fissure, or a simple ulcer. It is 
frequently cauterized with a mild caustic— nitrate of 
silver, sulphate of copper, or some similar applica- 
tion — but a cure is not effected. The habits of spirit- 
drinking, smoking and chewing of tobacco, and the - 
use of irritating food, all combine to keep up a 
chronic irritation of the sore, and thus is developed a 
cancerous degeneration of the epithelium. 

It should be carefully noted that nearly all the 
causes named, both predisposing and exciting, are of 
a character to be successfully treated or avoided if the 
physician has a just appreciation of their relation to 
the development of cancer. The average age of my 



— 53 — 

eases, when the disease was first discovered, was fifty- 
two years, so that when a man of that age, or older, 
presents himself with an ulcer of the tongue, it should 
be considered as a pre-cancerous disease at least, if it 
has not already passed across the line into the region 
of incurable disease. 

TREATMENT. 

The extreme difficulty in the way of successful 
treatment depends upon the histological character 
of the tongue. An organ of spongy tissue, with a 
wealth of blood-vessels and nerves; an organ almost 
always in motion, and, by its very location, extremely 
liable to irritation, furnishes an unrivaled soil for the 
dissemination of the cancer elements far beyond the 
original seat of the disease. The first requisite for 
our guidance in instituting a plan of treatment is to 
treat it early and thoroughly. While this is true of all 
cancer, wherever located, it is, if possible, more neces- 
sary in cancer of the tongue than in disease of any 
other organ. As a rule, caustics are not admissible. 
The pastes of all descriptions are dangerous on 
account of their deadly ingredients. If extreme care 
is used, the fused potash or soda may be applied to 
disease of the tongue in the very earliest stage. 

A man, aged thirty-five, who had been syphilitic 
for several years, developed a warty growth on the 
left border of the tongue one and a half inches from 
the tip, upon the site of an old ulcer. It was indur- 



— 54 — 

ated, somewhat painful, and a renewal of specific 
treatment failed to reduce it in. size, or even to modify 
its character. It was completely destroyed by caustic 
potash at one sitting, and after nine years it has not 
recurred. I believe the growth was malignant. The 
actual cautery in any form would have been equally 
efficacious, but is a more formidable agent in the es- 
timation of the patient. Mild cauterization, as I have 
before remarked, is extremely harmful in cancer of 
the tongue, and many cases which call for a formid- 
able operation have been stimulated to rapid and 
destructive growth by these applications. Unfortun- 
ately, the disease is usually pretty well advanced 
before we are consulted in regard to treatment. 

Seventeen years ago I first witnessed an amputa- 
tion of the tongue by Prof. Henry B. Sands. The 
method employed was the same now employed by 
Morant Baker, except that the galvanic £craseur was 
used instead of whipcord. The mouth was well 
opened, and the attachments to the jaw divided by 
scissors, passed as near the bone as possible, until the 
tongue was free some distance beyond the seat'of the 
disease. A strong silk loop was passed through the 
two tips of the tongue, for traction purposes, and the 
tongue then incised in the middle of the dorsum, and 
the two sides separated at the septum down to its 
root. Then long, blunt needles were passed through 
on the line of the proposed removal, the loop of the 
£craseur passed behind the needles, and the first half 



— 55 — 

slowly cut away with the wire, heated only to a red 
heat. This process is to be repeated for the other 
half when deemed necessary, which, I am inclined to 
believe, is always preferable to a partial amputation. 
This operation is strongly advocated on the ground 
that it is attended with a considerably smaller mor- 
tality than a cutting operation. However, bleeding 
vessels, if there be any, are not so securely tied 
after this method of removal as after an ordinary 
operation, and, while less blood is lost during the 
removal, secondary haemorrhage is more likely to fol* 
low, and, during the separation of the slough, septic 
infection is more liable to ensue than when a clean 
cut is granulating. The importance of thorough and 
frequent cleansing and disinfecting of the surface 
now appears to me of vital moment, and it is possible 
that by doing this the stump can be kept free from 
suppurative processes, even after the galvano-caustic 
operation. A battery, even of the most approved 
make, is sometimes imperfect, and special skill in its 
management is absolutely essential. 

It is usually more desirable to remove the tongue 
by some of the well known operations, and of these I 
shall only refer to Kocher's, Billroth's, and White- 
head's methods. Kocher attempts to prevent the 
somewhat frequent accident of septic pneumonia, by 
plugging the pharynx with antiseptic gauze after in- 
serting a tracheotomy tube, the patient being fed 
twice a day when the packing of the pharynx and 



-56 - 

mouth is removed. Incision is made along the side 
of the neck into the floor of the mouth, and this is 
preceded by ligature of the lingual artery in both 
Kocher's and Billroth's operations. It is needless to 
say that the operations are complicated ones and 
often difficult, and in Kocher's the tracheotomy is an 
added danger, which counterbalances any immunity 
from pneumonia which the packing of the pharynx is 
intended to prevent. The amount of shock is con- 
siderably increased by the tracheotomy and ligation 
of the artery. 

Whitehead's operation is far simpler in its de- 
tails, and, in my experience, quite satisfactory. I 
have never had a death due to any fault of the 
method. A good gag (I prefer O'Dwyer's to any 
other), a pair of curved scissors, and some Halstead 
artery forceps are the only instruments required. 
After the attachments to the jaw and floor of the 
mouth are divided and the tongue split, each half is 
well pulled forward by the traction loops which are 
held by assistants, and the tongue is snipped off with 
the scissors, the ranine artery being caught the 
moment it is divided, or even before. Should there be 
any difficulty in placing a good ligature, the clamp 
may be left in place for forty-eight hours, after which 
the vessel will not bleed. Mr. Christopher Heath's 
valuable suggestion should never be forgotten, even 
by the nurse, that haemorrhage may be controlled by 
hooking the finger over the root of the stump, and 



— 57 — 
dragging it forward, thus producing firm and efficient 
pressure. 

They tell us that any enlarged glands should be 
removed before the tongue is cut, but I would modify 
this rule by saying that, if the glands are enlarged, it 
is not a suitable case for operation of any de- 
scription. I know of no justifiable operation in case 
of recurrence of the disease after amputation of the 
-tongue. The after-treatment often determines the 
success or failure of whatever method of removal has 
been adopted. The wound should be kept lightly 
dusted with aristol or iodoform, and for a week at 
least the patient should be fed artificially by means of 
a tube passed into the stomach, or by nutritive ene- 
mata, or by both, according to the requirements of 
the case. The mouth should be frequently sprayed by 
an antiseptic fluid, but no attempt at the use of a gargle 
or lotion should be made, for the most perfect rest of 
the stump is necessary -for at least one week. 

The removal of the tongue for cancer involves 
some risk under the most favorable circumstances, 
the mortality ranging from seven to twenty *per cent., 
-according to the statistics of various authors. A fair 
idea of the results of operations in other cases may 
be gained from Mr. Butlin's table of seventy cases.* 
Eight died of the operation itself; in nineteen there 
is no record; thirty-two were dying of recurrence, or 



Operative Surgery of Malignant Disease. 



- 5» - 

dead; in only, five cases was, there a complete and 
perfect cure extending beyond the three-year limit. 

Several of my thirty-four cases were incurable 
before they came under my care. Of those treated, 
the one where caustic potash was used remains well 
after nine years; one is still under the aniline chloride 
treatment; one has recurrence in the glands one and 
a half years after operation, and the others, as far as 
we are able to complete the history, are dead. I am 
forced to the conclusion that cancer of the tongue is- 
one of the most deadly of the whole group, and, un- 
less removal is undertaken in the very earliest stage 
of the malady, the prognosis is most unfavorable, and 
is never good in any case. 



CHAPTER VII. 

CANCER OF THE FEMALE BREAST; FREQUENCY, 

/ETIOLOGY, AND CLINICAL FEATURES; 

DIAGNOSIS. 

The most frequent form of cancer in the female 
breast is scirrhus carcinoma. In Satterthwaite and 
Porter's table of one hundred unselected cases of can- 
cer, forty-one belonged to this class. In the 10,759 
cases reported by Marsden, 5,706 were scirrhus — 
more than one-half. In my own table of 534 cases, 
139 were in the female breast, and of these 89 were 
scirrhus. We properly assume, therefore, that this 
variety of cancer is typical, while the various other 
forms are more or less widely divergent modifications 
of scirrhus. The term " cancer of the female breast " 
is considered more comprehensive than "cancer of 
the mammary gland," because all cancer of the breast 
does not belong to the mammary gland primarily, but 
invades the gland by the usual methods of extension 
which, in breast cancer, according to Mr. Bryant,* 
are as follows: 

"1. By continuous local infection, or other 
gradual involvement of surrounding structures, in the 
order of their arrangement around the primary seat 
of the disease; by progressive infiltration, as well as 



* Diseases of the Breast. 



— 6o — 

by extension along the perivascular sheaths of the 
blood-vessels of the diseased part, this being a com- 
mon feature of scirrhus. 

" 2. By lymphatic infection, by which is meant 
the infiltration of the lymphatic glands associated 
with the primary diseased centre, or its coverings; by 
the lymphatic ducts, which carry the cancer elements 
to the glands by the lymph, or the ducts themselves 
become directly infiltrated. 

" 3. Secondary or vascular infection, by which 
is meant the propagation of the disease through the 
blood currents. By this method probably multiple 
secondary growths, similar to the primary disease, are 
found in the viscera or other parts of the body, often 
remote from the primary seat of the disease." 

I must be permitted to take exception to Mr. 
Bryant's unqualified statement that in carcinoma of 
the breast the gland structure is the one primarily 
involved. If that were absolutely true, Dr. S. W. 
Gross* title of " cancer of the mammary gland " 
would be the more correct one. The cancer follow- 
ing eczema of the nipple primarily involved the skin 
and secondarily invaded the mammary gland. Un- 
doubtedly the vast majority of cases originate in the 
gland itself, but there are many exceptions to the rule. 

A patient, fifty-nine years old, applied for treat- 
ment February 21, 1889, With a large scirrhus tumor 
of the left breast, which had invaded the axilla and 
encircled the axillary vein in its growth. It began 



— 6i — 

four years before as a small tubercle in the skin, about 
half an inch above and outside of the nipple. 

Another patient, aged fifty-two, was treated by 
operation March 3, 1890, whose disease (scirrhus) 
began in a fissure of the nipple which had not healed 
since the last child was nursed, eight years before. 
From this point the entire mammary gland had be- 
come infiltrated with cancer. 

Mrs. M. K., aged thirty-eight, was operated upon 
June 25, 1887, for the removal of a scirrhus carcinoma 
of the left breast, which began in a wart on the skin 
near the nipple. Several other cases are recorded in 
my note-book, where cancer of the breast did not 
originate in the mammary gland, but the above 
histories are sufficient to show that Mr. Bryant's state- 
ment should have been somewhat less positive. 

ETIOLOGY OF CANCER OF THE BREAST. 

Some points in regard to the cause of cancer of 
the breast are of such importance that I wish to 
briefly consider them, even at the risk of repeating 
what has been said in a previous chapter. As in can- 
cer of the lip, and of various other parts of the body, 
a prolonged irritation is sufficient to produce malig- 
nant disease, so in breast cancer we find this fact fre- 
quently emphasized. A striking example of this is 
the final development of cancer of the female breast 
beginning in the remains of an old mammary abscess, 
occurring five, ten, and even twenty years before. 



— 62 — 

The patient will tell you that there was always a little 
lump there, and the soreness remaining after the ab- 
scess was cured had never entirely disappeared. The 
cancerous disease began when the patient reached 
that time in life when such degeneration usually 
occurs. Traumatism is an important factor in the aeti- 
ology of this class. In my 139 cases, twenty-three 
.gave a reliable history of a blow, or some other injury, 
with which she connected the development of the 
tumor, and in most instances, I have no doubt, the 
patient was correct. In one instance a watch had 
been carried in the bosom for many years, resting 
upon the same portion of the breast year after year, 
until a slight tenderness and pain were noticed, which 
gradually increased until the watch was removed and 
the breast examined, when I found a small tumor, 
which was removed, and by microscopical examination 
proved to be cancer. 

The fact is that a study of the causes producing 
these neoplasms of the female breast indicates, be- 
yond reasonable doubt, that the so-called " local " 
origin of cancer, as opposed to the theory of a " con- 
stitutional " cause, is correct. It would seem to be 
unnecessary to argue in favor of the local theory 
after the discussion of the subject in the London 
Pathological Society in 1874, which Mr. Jennings* 
has recently reviewed, were it not for the fact 



* Cancer and Its Complications. 1889. 



- 63 - 

that many doctors and patients continue to regard 
cancer as a " blood disease," and consequently in- 
curable by operative procedures. The evidence in 
favor of the purely local origin of cancer is now so 
generally credited by those who have studied care- 
fully the natural history of the disease, that Sir James 
Paget stands almost alone in his advocacy of the 
"constitutional " theory. Several times during the 
past few years we have been upon the very threshold 
of the discovery of the cancer bacillus, and when it is 
found, as it doubtless will be, the last support of the 
"constitutional" or "blood origin" hypothesis will 
be swept away. Permit me here to quote Mr. Jen- 
nings' conclusion in full upon this point: 

" i. Cancer first affects the body locally, spreads 
locally, and invades the body along definite tracks 
(lymphatic and vascular systems). 

"2. Cancer grows plant-like in a congenial soil. 

"3. Some soils are more congenial than others 
to the development of cancer (predisposition), and 
tissues peculiarly favorable to the propagation of 
cancer, or the reverse, may be acquired by inheri- 
tance. 

"4. The disease can be completely eradicated 
by surgical operations; and, when they fail, the in- 
ference is that they had not been undertaken suffi- 
ciently early nor with sufficient boldness." 



- 64 - 

CLINICAL FEATURES. 

The following history of a case, which was under 
my care from the very commencement to its fatal 
termination, and in which the patient persistently re- 
fused all treatment until it was too late to secure 
even a palliation of symptoms by operation, furnishes 
an excellent description of the clinical features of the 
disease: Mrs. R., age 62, widow, the mother of sev-^ 
eral children, had always been healthy until one year 
ago, when she fell from a chair and received a con- 
tusion of the right breast, which, it should be stated, 
was large and pendulous. It was painful and very 
tender for a few days, after which a small, sharply 
circumscribed portion only attracted her attention if 
pressed upon by the clothing or otherwise. After 
six months this point began to increase in size, a 
slight enlargement of the breast was observed,, 
which steadily increased from that time, until at 
the end of eighteen months the entire mammary 
gland was of a stony hardness, darting pains were 
frequent in the breast and along the course of 
the lymphatics into the axilla, along the arm, and 
even down the forearm. At this time some of the 
axillary glands were enlarged. The tumor became 
less movable on the chest wall, and from the nipple, 
which had become retracted, a few drops of sero- 
sanguinolent fluid occasionally exuded. The skin 
over the tumor became gradually livid on the most 
prominent portion, the tumor began to soften, finally 



-65 - 

ulcerated, and a fungoid growth sprang up, which in 
turn broke down, and the open sore steadily became 
larger and deeper, until me thin and offensive dis- 
charges kept the clothing saturated, nothwithstanding 
the utmost care on the part of the attendants. This 
was two years from the beginning of the disease, and 
then appeared the general constitutional symptoms. A 
large tumor of the supra-clavicular gland of that side 
appeared, and the patient lost appetite, strength, and 
flesh. Loss of sleep and occasional haemorrhages 
(not profuse) carried her rapidly along the downward 
road, until the end of the third year, when she died. 
For three months the entire upper extremity had 
been cedematous and utterly useless. There was no 
history of heredity, and her knowledge of the family 
was unusually complete. This record, with a few 
minor changes due to age, differences of tempera- 
ment, and variety in the exciting cause, would repre- 
sent the symptoms and course of the vast majority of 
cases of cancer of the female breast. In a younger 
patient its course would probably have been shorter; 
in an older one it might have been prolonged much 
beyond three years. Dr. John T. Kennedy, of New 
York City, has recently informed me of an undoubted 
case of cancer of the breast of seventeen years' dura- 
tion, and the patient is still in good general health. 

I have had only one other case which followed 
its natural course, and that patient lived seven years, 
and the constitutional infection did not occur until 

5 DDD 



— 66 — 

the last year of life. Both of these tumors were car- 
cinoma, and my experience has not demonstrated 
the correctness of the opinion held by some writers, 
that traumatism is more often followed by sarcoma 
than by any Other form of cancer. 

DIAGNOSIS. 

It is desirable to make an accurate diagnosis in 
all cases of tumor of the female breast, yet I repeat 
that non-malignant neoplasms in this organ are un- 
doubtedly so frequently the precancerous stage of the 
disease that we should not insist upon a positive diag- 
nosis before deciding to remove the growth. 

By a careful study we may usually classify these 
tumors, and make the differential diagnosis sufficiently 
early to insure the success of operative treatment. I 
have found such satisfaction in the rules laid down 
by Dr. S. W. Gross* that I am certain we cannot find 
a more complete statement of the subject than can be 
gained by a review of his conclusions. The first rule 
he lays down should not be neglected, viz.: Both 
breasts should be fully exposed for purposes of com- 
parison, and the patient be placed in a recumbent 
posture. By this means the resistance of the chest 
wall enables us to detect any nodule, however small, 
which might escape detection if the gland is simply 
pinched up between the thumb and finger, while the 



Tumors of the Mammary Gland, Chapter xi. 



- 67 - 

patient is sitting or standing. The great advantage 
of this mode of examination has- been demonstrated 
in my own practice frequently. 

Gross has compared carcinomatous with non- 
carcinomatous tumors, and included the sarcomas in 
the latter class, a distinction which I believe is often 
misleading, and the term cancerous tumor is better for 
clinical purposes. Inasmuch as his cases of carcinoma 
outnumber all others in the proportion of more than 
5 to i, we may make safe deductions therefrom. 

AGE OF DEVELOPMENT. 

The average age of cancer patients is forty-eight 
years, and it never develops before the twentieth year 
— 77.26 per cent, develop after the age of forty. In 
impubic girls the idea of cancer may be discarded. 

HEREDITARY PREDISPOSITION. 

Cancer is traceable to heredity in 11.28 per cent, 
of all cases, while non-cancerous tumors do not ap- 
pear to be inherited. 

SITUATION. 

Most common at upper and outer margin, and not 
infrequent near the nipple. The non-cancerous growths 
usually at the upper and inner circumference, rarely 
near the nipple. 

CONSISTENCE. 

Uniformly densely hard and inelastic throughout, 
except in rare instances of combination with an invo- 



h 



— 68 — 

lution cyst, when there is a limited spot of fluctuation. 
As an exception, may be firm and elastic, or even soft 
and fluctuating. 

MULTIPLICITY. 

Several tumors are rarely present in the same 
breast. 

MOBILITY. 

Move with the gland of which they form a part, 
and cannot be isolated. Attachments to the skin and 
chest are common, and frequently extensive. Non- 
cancerous tumors glide and roll under the fingers, 
and move freely within the mamma and on the adja- 
cent parts. 

STATE OF THE NIPPLE. 

The nipple is permanently retracted and fixed in 
52 per cent, of all cases, and is often infiltrated. A 
thin, sanguinolent discharge is met with in 9 per cent, 
of all cases, but it is never copious. 

CONDITION OF THE SKIN. 

The skin, even when the tumor is not larger than 
a hazel-nut, provided it be superficial, is dimpled and 
adherent. In larger growths it is adherent, thinned, 
or discolored, or rigid and brawny from specific infil- 
tration in 34.54 per cent, of all cases, and the seat of 
distinct nodules in 10.61 per cent. In other tumors it 
is never dimpled nor the seat of secondary tubers. 



-6 9 - 

LYMPHATIC GLANDS. 

The axillary glands are enlarged and hard when 
the patient first comes under observation in 64.23 per 
cent, of all cases, and in one out of every 22 instances 
the glands of the neck are also involved. In other 
tumors the axillary glands are enlarged in only 2.98 
per cent, of all examples, and the supra-clavicular 
glands are never implicated. 

Under the above headings I have given Prof. 
Gross' percentages, but they correspond with my own 
to a remarkable degree. While I have copied his own 
words for the most part, I have given only the points 
of greatest value, and they are sufficient to render a 
diagnosis of cancer of the breast easy and certain in a 
vast majority of cases. 



CHAPTER VIII. 

CANCER OF THE FEMALE BREAST (CONTINUED) 
— TREATMENT ~ CAUSTIC TREATMENT 
NEVER TO BE RECOMMENDED-OPERA- 
TION — DETAILS OF OPERATION- 
DRESSINGS— RESULTS— CAN- 
CER OF THE MALE BREAST. 

TREATMENT. 

Many elaborate plans have been formulated and 
recommended, looking to the removal of cancer of 
the breast by caustic applications. While these differ 
one from the other in the agent employed, or in the 
methods of using them, the effects are substantially 
the same, namely, the production of a slough in the 
diseased tissue and its surroundings, leaving a deep 
irregular ulcer to be healed by granulation. 

It is not necessary, for my purpose, to review all 
the different methods, but I will give a single instance 
of the use of Marsden's paste, in a cancer of the 
breast, which came under my notice. 

Mrs. B., aged 55, who, thirty years previously, 
had an epithelioma of the nose successfully treated 
by a caustic, developed a scirrhous tumor of the left 
breast, which involved a considerable portion of the 
gland, although there was no disease of the axillary 
glands. It was as good a case for the use of caustics 
as we ever find in the breast, and Marsden's paste was 



— 71 — 

applied by the attending physician, according to the 
rules which have been given in a previous chapter. 
In due time a large slough separated, but it was 
evident that the deeper portion of the ulcer was still 
cancerous. The paste was re-applied to this portion, 
which was in the lower part, of the excavation and 
about three-quarters of an inch below the surface. 
There was considerable secretion from the ulcer at 
the time of the application, and as the patient was 
lying in bed, some of this purulent matter collected 
in the groove where the paste was applied, kept it 
somewhat softened, and its caustic effect was not 
satisfactory. The natural sequence was the absorp- 
tion of the poison, and a general paralysis occurred, 
affecting all the extremities, and rendering the pa- 
tient permanently helpless. At this juncture I saw 
the case for the first time, and removed the entire 
cicatrix by operation. The healing was satisfactory, 
and although the patient lived eight years afterwards, 
there was no recurrence of cancer. The immediate 
cause of death was some acute affection, but the 
arsenical paralysis continued to the last. All will 
agree that in this instance caustic treatment was a 
failure, and it is my judgment, after repeated observa- 
tions of such treatment, that no case of cancer of the 
breast can be as successfully managed by caustics as 
by operation, and it is my habit to advise patients to 
avoid their use, as such treatment is tedious, painful, 
ineffectual in most instances, and often dangerous. 



— 72 — 

Even Bougard's paste, which I have so highly recom- 
mended in the treatment of cancer of the skin, is open 
to the same objections as all other caustics, and should 
also be discarded in breast cases. 

OPERATION. 

The operation for removal of a cancerous breast 
is comparatively simple, especially when the disease 
is limited to the mammary gland. If the axillary or 
subclavicular lymphatic glands have been invaded, or 
in cases where the skin is extensively diseased, the 
operation is often both formidable and difficult. 

Two important points in regard to the operation 
are still under discussion by surgeons. The first 
refers to the advisability of opening the axilla when 
the glands are not the seat of disease. The answer 
should be positively in favor of doing so, when we 
consider the incontrovertible fact that recurrence 
occurs in these glands in a very large proportion of 
cases. It is but common sense to declare that, if the 
glands are removed, one great danger of recurrence 
is thereby avoided. It is also true that we are never 
able to decide with certainty that the axillary con- 
tents are free from infection until we have exposed 
them to view. In one instance it was the opinion 
of my assistants, as well as my own, that the lymph- 
atics were healthy before the incision was made, but 
afterwards the entire chain of glands, from the breast 
to the axillary space, and under the pectoral muscles 



— 73 — 

as well, were found to be cancerous, and twenty-seven 
glands, with all the cellular tissue surrounding them, 
were removed. It should be noted that the operation 
was nine years ago, and the patient is still living and 
has never had a recurrence. The disease was scir- 
rhus carcinoma. 

If we leave the axillary contents undisturbed, a 
recurrence of the disease is not only to be feared, but 
is actually rendered probable. It is almost as repre- 
hensible surgical practice as to leave a portion of the 
mammary gland when the tumor happens to be small, 
a proceeding which no one of mature judgment now 
considers for a moment. We are told that to remove 
the contents of the axilla considerably increases the 
dangers of the operation. My own experience does 
not sustain that opinion. Although I have made it. an 
invariable rule for many years to open the axilla, I 
have yet to see any serious consequences therefrom, 
and the extremely small death rate from the operation 
has not been increased. The danger from amputation 
of the breast is not to be considered for a moment 
when compared with the risk of recurrence of the 
disease, and I repeat that this is vastly diminished by 
opening the axilla. 

The other mooted question has been prominently 
brought forward by Dr. S. W. Gross, who carried our 
argument in favor of the axillary operation (which he 
advocated) still further, and advised the removal of a 
very large section of the skin over and around the 



— 74 — 

breast, leaving an extensive wound to heal by granu- 
lation. He recommended removal of the breast by a 
circular incision, which would include all the mam- 
mary gland and its coverings, together with all para- 
mammary tissues, fascia, adipose tissue, and muscle, 
and, of course, making it impossible to leave any flaps 
which could be brought together. In some extreme 
cases this procedure is a necessity, but to make such 
an operation the rule in all cases is unwise. In the 
tedious process of healing such a large surface by 
granulation, with the resulting extensive cicatrix, a 
new cause of recurrence is encountered. This • is 
especially the case if the cicatricial tissue develops a 
tendency to contract, as is frequently the case. The 
safer course lies in prompt, rapid, and complete union 
of cutaneous surfaces, such as can always be secured 
if an early diagnosis and immediate removal are 
effected. The advantages of this course are so evi- 
dent that I have been enabled to make the prognosis 
with certainty by noting whether we have a rapid or 
tardy reparative process after the operation. 

DETAILS OF THE OPERATION. 

The special preparation of the patient for the 
operation of removal of the breast and the axillary 
contents consists in cleansing and shaving the skin of 
the axilla, and thoroughly rubbing into the entire 
field of operation a one-per-cent. solution of carbolic 
acid in pure olive oil, as recommended by Mr. Nunn.*- 



* Nunn on Cancer of the Breast. 



— 75 — 

This should be done on the day preceding the opera- 
tion. All antiseptic precautions should be thoroughly 
observed, for we aim to secure primary union of the 
axillary incision and as much of the remaining cut as 
possible. 

The patient is placed squarely upon the back 
and an assistant holds the arm steadily at right angles 
with the trunk, and not above that point, as some sug- 
gest, for by that means the axillary vessels are drawn 
out of their natural relations, and thus possibly con- 
fuse the operator. The amount of tissue to be in- 
cluded in the elliptical incisions is to be determined 
entirely by the extent of the tumor, ample distance 
being allowed for an extension of the infiltration be- 
yond the line of evident disease. The general direc- 
tion of the incisions should nearly correspond with 
the fibres of the great pectoral muscle, as the best 
drainage is thereby secured while the patient is in a 
recumbent posture. Then with a sharp scalpel, so 
held that the plane of the blade is vertical to the skin, 
which is held taut by the thumb and fingers of the 
left hand, by a single sweep the first incision is carried 
from a point near the sternum under the breast to a 
point on a vertical line from the axilla. If possible, 
cut all adipose and connective tissue to the fascia by 
this first stroke. Clamp any vessels large enough to 
require it, and make the opposite upper incision to 
meet the two extremities of the first one. Then, 
grasping the included mass with the left hand, it is 



- 76 - 

rapidly detached down to the muscles beneath and 
removed. While Mr. Stile's method of detecting 
whether the incisions have been through diseased 
tissue by treating the part removed with dilute nitric 
acid, which turns the cancerous tissue white, is an 
ingenious one, it should be unnecessary, for we at 
once proceed to remove all cellular tissue left in the 
floor of the wound, then the fascia, and finally the 
muscle itself, in every instance. All vessels which have 
been secured by the forceps are then tied, and the 
cavity filled with a towel wrung dry from very hot 
carbolized or bi-chloride water, taking care before 
doing so to loosen the flaps well to facilitate bringing 
them together afterwards. The incision for the axil- 
lary operation is then carried from the outer angle of 
the wound along the border of pectoralis major en- 
tirely beyond the axilla, and then the dissection must 
be carefully made with the handle of the knife and 
the fingers until the axillary vein is reached, which 
must be the starting point of all satisfactory work in 
these cases. Then by working downward, using the 
blade of the instrument or scissors but seldom (after 
the flaps have been well turned back), the remaining 
removal is very easy. If the tumor is found to have 
involved the axillary vessels, we have a complication 
of grave import, and in such cases recurrence is cer- 
tain, -no matter what course we take regarding it. I 
believe it is just as well to close the wound after re- 
moving what lies below the vessels as to undertake 



— 77 — 
the difficult task of ferreting out disease which has 
implicated the vessels and invaded the space beyond 
them. The next step consists in examining under- 
neath the pectoral muscles and removing all glands 
there found as far as the lower border of the clavicle, 
using the fingers alone in this search. Cut the muscles 
away, if they are diseased, without the slightest hesi- 
tation, as the patient may have very good use of the 
shoulder without them. 

After ligating the vessels, fill this cavity with a 
hot towel also, and proceed to close the first wound, 
by a continuous horse-hair suture, beginning at the 
sternal end. If the flaps are too short in some places 
to unite, bring them as near together as possible, and 
afterwards relieve tension upon »them by fastening 
strips of gauze an inch and a half wide and eight 
inches or more in length to the skin above and below 
with collodion, and then tie the opposite ends se- 
curely together. This is a suggestion of Bougard's 
which I have found valuable in many cases. Then 
paint the sutured line with aristol collodion (1.-30.). 
Beginning at the outer end, close the axillary incision 
in the same manner, placing a little bundle of horse- 
hair in the cavity for drainage. It is seldom neces- 
sary to place any drainage in the first or mammary 
wound. In fact, a drainage tube here often delays 
repair. A layer of moist aristol gauze is then laid 
over the entire wound, and this in turn, and the well 
breast, covered with a thick layer of cotton, and a 



- 7 8 - 

six-inch gauze bandage firmly applied. The bandage 
should finally inclose the arm, but the forearm should 
be left free, and placed in an ordinary sling. Then it 
can be occasionally straightened, and in this way the 
entire limb is rendered more comfortable, and a better 
circulation therein secured. 

It may be stated here that my reason for prefer- 
ring horse-hair to any other suture is that by simple 
washing it can be made perfectly aseptic, and it can 
be left in position indefinitely, without the slightest 
irritation or suppuration, and it is as indestructible as 
silver wire. If the hair is wet, it becomes as pliable 
as catgut, and can be as securely fastened by the 
ordinary knot. 

For several reasons I prefer the continuous 
suture, and a little device suggested to me by Dr. J. 
F. Aitken in regard to fastening the ends is valuable. 
It consists in leaving a long end to the hair as last 
brought out, and running a loop through the opposite 
flap when the double end and the single one can be 
easily and firmly tied. The advantage of this little 
manoeuvre will be fully appreciated after you have 
tried the ordinary ways of making a single end fast 
without allowing the suture to slip. 

I never change or disturb the dressing under five 
or six days unless it becomes moistened by drainage, 
or some rise in the patient's temperature is noticed, 
when the dressing should be changed. The subse- 
quent care of the wound is to be determined by 



— 79 — 

circumstances, and requires no special mention. I 
have been thus minute, and even elementary, in 
describing the operation simply because regard to 
these comparatively unimportant details, if neglected 
even in part, often jeopardizes the success of the 
operation. 

I wish to add a few words regarding the results of 
the operation. In my cases only two deaths have oc- 
curred as the immediate sequence of the operation. One 
of these was extremely septic at the time we operated, 
and I suffered from a severe inflammation of one 
finger, and one assistant had a similar uncomfortable 
experience. The patient died of peritonitis. The 
other fatal case was a patient who had been living in 
a malarial district, and a violent intermittent fever 
caused death from exhaustion, one week after the 
operation. Thus we are justified in saying that the 
danger from the removal of the breast by operation 
is very slight indeed. 

All the patients who had disease in the neighbor- 
hood of the axillary vessels have suffered from recur- 
rence, and, as far as their histories can be verified, 
have died of the disease. 

In this class of cases, then, the prognosis is 
always unfavorable. 

In the other cases we can report a number of 
permanent cures. One is well after fifteen years, one 
after nine years, another died of a different disease 
eight years after operation, and twenty are known to 



— 8o — 

have passed the three-year limit and remained welL 
Several have had slight recurrent growths removed,, 
and are still free from disease and in good health. 
We have here, then, to repeat what we have so often 
said regarding cancer in other parts of the body, viz., 
that if the operation is performed at a very early stage 
of the disease, success is almost assured; but if treat- 
ment is delayed for years, months, or even weeks after 
the tumor is discovered, it is at the patient's peril, and 
no surgeon should ever consent to such fatal procras- 
tination. 

CANCER OF THE MALE BREAST. 

There is no especial interest connected with can- 
cer of the male breast except regarding its frequency. 

One case of my 141 occurred in the left breast of 
a man of 42, who received a blow about a year previ- 
ously. There was no axillary involvement, and the 
tumor, which was as large as a goose-egg, was easily 
removed, and proved to be a spindle-celled sarcoma. 
He died within a year, of a general sarcomatous dis- 
ease appearing in the form of over one hundred 
nodules on the skin all over the body, varying in size 
from -a pea to a walnut. He gave no family history 
of cancer, and was a splendid specimen of muscular 
development, even when the operation was performed. 

Dr. S. W. Gross has made a resumd from different 
authorities, showing about the same relative frequency 
as my own: 

"Sir James Paget believes that of every 100 



— 8i — 

cases of cancer of the mamma only 2 occur in men. Of 
102 examples of which I (Gross) have a record, I have 
seen only 2 in males. Billroth, out of 252 cases, had 
7; and Henry, out of 196 examples, saw 4 in men; so 
that the proportion is as 1 to 42." 

While this proportion is larger than my own 
cases indicate, the total number is so exceedingly 
small that cancer in the male breast must be classed 
among the extremely rare affections. 

6 DDD 



CHAPTER IX. 

CANCER OF THE UTERUS— EARLY DIAGNOSIS 
THE ONLY HOPE FOR THE PATIENT— THE 
PRE-CANCEROUS STAGE— TREATMENT: 
CAUSTICS; TOTAL EXTIRPATION- 
DISINFECTANT FOR PA- 
TIENT'S ROOM. 

Twenty cases of cancer of the uterus, or less than 
4 per cent, of the entire number, are recorded in my 
table in Chapter XII. This is not to be regarded as 
any index of the comparative frequency of the dis- 
ease. Cancer of the uterus is usually discovered and 
treated by the gynaecologist who*is consulted for 
what the patient supposes to be some ordinary uter- 
ine disease. In the New York Skin and Cancer Hos- 
pital, where there is a special clinic for internal cancer 
in women, in 1890, twenty-two per cent, of all patients 
with malignant disease were found to have cancer of 
the uterus. In the Paris Register, among 8,289 fatal 
cases of cancer, 2,996 were uterine, or upwards of 
thirty-six per cent. This, however, may be taken 
rather as a proof of the fatality of the disease in this 
organ than of its relative frequency. On the other 
hand, Satterthwaite's* percentage was four and eight- 
tenths per cent. 



*One Hundred Cases of Cancer. 



- 8 3 - 

One point is indisputable, after studying all the 
records before me, viz., that cancer of the uterus im- 
mediately follows malignant disease of the breast as 
to frequency, and outranks breast disease in its fatal- 
ity. My number of cases (20) is not sufficient to ren- 
der deductions of much scientific value, as several of 
them were absolutely incurable before they came 
under my care, but some general characteristics seem 
to be of sufficient importance to demand careful con- 
sideration. 

In the first place, there is no class of cases where 
the disease is more likely to be undiscovered than in 
the uterus, and at the same time all hope of cure must 
be abandoned unless a diagnosis is made at the very 
earliest stage of the disease. Have we, with our pres- 
ent knowledge, any means of making this early diag- 
nosis ? Although Williams* has told us that it can be 
done by the aid of the microscope, especially when 
the suspected disease is in the portio vaginalis, still I 
doubt the possibility of making an accurate diagnosis 
in many cases, even by the most skillful pathologist. 
The anatomical division of the organ into the vaginal, 
cervical, and corporeal segments is of the greatest 
convenience for classification, but it is as useless as 
possible in determining how far the infiltration may 
have extended, for, from a clinical standpoint, the 
divisions are as imaginary as the imaginary lines upon 



* Cancer of the Uterus: Harveian Lectures, 1886. 



- 8 4 - 

the page of a geographical atlas. As in the tongue 
we are never certain that cancer tissue has not been 
developed far beyond the apparently diseased portion, 
so in the uterus we have an organ with no natural 
barriers to even hinder the fatal progress of the mal- 
ady. It is certainly true that clinical examination in 
these cases is less satisfactory than elsewhere, for the 
characteristic induration, such as belongs to cancer of 
the skin, for example, is often wanting until quite late 
in the history. 

Subjective symptoms do not aid us oftentimes in 
making a diagnosis in the curable period of uterine 
cancer, if, indeed, there be such a period. A patient 
consulted me several years ago for a marked general 
debility, the cause of which I was for a time unable 
to discover. She complained of no pain, and gave no 
symptom pointing to disease of any special organ, 
until at last she incidentally remarked that sometimes 
she had a little leucorrhcea. An examination revealed 
the most extensive epithelioma of the vagina, portio 
vaginalis, and cervix which I have ever seen. From 
the osteum vaginae in every direction, and almost 
filling the canal, was this enormous neoplasm of the 
most malignant type, which proved fatal a few weeks 
later. The patient had never suffered from pain, not 
even a backache. She was sixty-eight years of age, 
and I wish to repeat here what has been previously 
stated, that age is almost a determining factor in 
diagnosis. The ages of my twenty patients naturally 



-8 5 - 

divide them into two classes: i. Those who were 

passing through the climacteric. 2. Women who had 

advanced some years beyond it. Their ages were as 
follows: 

Between 42 and 45 7 cases. 

Between 45 and 50 6 cases. 

Between 50 and 60. ...... 6 cases. 

Between 60 and 70. I case. 

It will be observed that there was practically no 
case in the childbearing period, while between 42 and 
50 years there were 13. The most important lesson 
to be learned from this fact is that a careful examina- 
tion should always be made of a patient during this 
period, if her symptoms indicate, in the slightest degree, 
any ulcerating disease of the uterus. Any chronic 
inflammation of the cervix, or old laceration, or any 
cicatricial tissue, whether from pre-existing disease or 
as the result of operation, should be frequently and 
carefully examined. I include old lacerations in this 
list, notwithstanding Williams' statement that he has 
never seen cauliflower growth starting from a tear, 
and is of the opinion that laceration plays no part 
whatever in the aetiology of that form of cancer. 
There is no reason to doubt that a chronic irritation 
of the tissues here will prove an exciting cause of 
cancer during this period (between 40 and 50) just as 
surely as such a condition will cause an epithelioma 
of the lip, tongue, or skin. 

In the case of patients between 50 and 70 years 



— 86 — 

of age, it may be said that a leucorrhoea or a metror- 
rhagia, however slight, is usually an indication of a 
tendency to uterine cancer, if not of its actual exist- 
ence. Sometimes a pessary will produce in old women 
an ulceration of a pre-cancerous character. Such a 
case has been under my care during the past two 
years. The patient was 67 years old, and, although 
the uterus had nearly disappeared, there was so much 
relaxation of the vagina that she had worn a flexible 
ring for a period of three years. It had not been re- 
moved in six months when she came to me with a 
suspicious ulcer in Douglas' cul de sac, which, under 
the most careful treatment with caustics, followed by 
aristol dressings, was nearly a year in healing. This 
leads me to repeat here what I have said elsewhere* 
concerning aristol as an application in ulceration of 
the uterus, both benign and malignant: 

" A most satisfactory result of the use of aristol 
powder was obtained in a number of cases of ulcera- 
tion of the cervix uteri. It was applied by means of 
an ordinary cotton tampon, smeared with vaseline, to 
which the powder adhered, then placed in position 
against the ulcer, and left from forty-eight to seventy- 
two hours. Induration, thickening, and suppuration 
were all promptly improved, and the ulcers, which 
had resisted prolonged treatment by glycero-tannin, 
borated solutions, and other applications in common 
use, finally healed. In no case was any irritation ex- 
cited by the remedy itself, the stimulating effect cor- 



- 8 7 - 

responding in degree to that of tincture of iron used 
in similar cases. 

"Another application in these cases, which is 
convenient and efficacious, is a mixture of aristol and 
iodol in equal parts, applied through the speculum 
by an ordinary powder blower, after which a light 
tampon of absorbent cotten may be inserted." 

The treatment of cancer of the uterus, when of a 
pronounced character, is usually of no permanent ben- 
efit. We should, however, attempt to cure the patient, 
especially if the disease seems to be confined to the 
portio vaginalis. I have attempted it in such cases 
by removal of the cervix and cauterizing with ter- 
chloride of antimony, the Paquelin cautery, and other 
agents, sometimes preceding their use by thorough 
curetting far beyond the internal os, and yet in none 
of my cases was an immunity from disease secured 
lasting over six months. In one case the entire uterus 
was removed by a skillful operator two months before 
the patient entered my service, and even in that short 
period a recurrent growth, the size of a foetal head, 
filled the entire pelvic cavity. It appeared to have 
originated in the parametrium, in the neighborhood 
of both broad ligaments. I am obliged to confess 
that all my twenty patients are dead, with one excep- 
tion, and she has only been under observation the last 
few weeks, and is going to follow the others in a few 



*New York Medical Record, June 6th, 1892. 



— 88 — 



months. As sad as my histories are, all my colleagues, 
as far as my personal knowledge extends, have an 
equally dismal report to make of the final results in 
their cases. 

We should not close this chapter, however, with- 
out referring to some of the brilliant immediate 
results of ablation of the uterus for cancer. In the 
first place, removal of the uterus should never be 
attempted if the disease has extended beyond the 
uterus itself. Under any circumstances, especially for 
the determination of that point, an examination should 
be made under an ancesthetic. 

The fatality of the operation of total extirpation 
has been somewhat lessened as surgeons have become 
more familiar with it, but it is still enormous. Freund, 
of Strassburg, lost seventy-two per cent, as a result 
of the operation, but Schrceder has reported forty 
cases with a mortality of only ten. Now, note the 
subsequent history of his remaining cases: 

14 had a respite of 1 year. 



iy 2 years. 

2 

3 

3^ " 

4 



30 

The last one died of apoplexy without recurrence 
of cancer. Here we find an average interval between 
the operation and recurrence (and they all had recur- 



- 8 9 - 

rence, except the one who escaped through an apo- 
plexy) of between two and three years. Several of 
them might have lived that length of time without 
any treatment. We had a case in the Skin and Can- 
cer Hospital which lasted over four years without any 
treatment beyond disinfecting douches, and the last 
months of her life were peaceful and painless. 

For the purpose of disinfecting the room occu- 
pied by cancer patients, in several instances I have 
used with satisfaction the following plan, suggested 
by Dr. H. Gesould, of Cleveland, Ohio: Dissolve 
12. grammes of nitrate of potash in 250. grammes of 
Piatt's chlorides, full strength. In this saturate thin 
muslin, and burn it in the room and under the bed- 
clothing as often as required. Its use causes no dis- 
comfort to the attendants or offensive odor in adjoin- 
ing rooms. 



CHAPTER X. 

CANCER OF THE RECTUM— HISTORY OF A, 
CASE— VARIETIES OF— CAUSATION— EX- 
AMINATION OF RECTUM— SYMP- 
TOMS— TREATMENT— CARE 
OF INCURABLE CASES. 

Cancer of the rectum is not of frequent occur- 
rence, only one per cent, of my own cases being in 
that location. In Marsden's table of 10,759 cases of 
cancer treated in the London Cancer Hospital,* 61 
were in the rectum, being slightly above one-half of 
one per cent. This table agrees with all others in 
showing a very large preponderance of males, the 
proportion being about six to one. 

The history of the following case illustrates the 
points which we wish to discuss in this chapter: 

Mr. A. H., sixty years of age, a farmer by occu- 
pation, has always been healthy until eighteen months 
ago. He never had piles, or fistula, or fissure, all of 
which are often predisposing causes of cancer. 
Neither does he give any family history of malignant 
disease or phthisis. His facial expression is that of a 
man suffering with severe constitutional disease. His 
appetite and digestion are poor, and he tells me he 



*Marsden on Cancer. 



— 9 I — 

has lost forty pounds in weight since the trouble 
began. 

His first symptom was an obstinate diarrhoea, 
which resisted all the usual treatment, and continues 
at present, it being usual for him to have a passage 
as often as every hour during the day. There is little 
pain during the stools, and only slight traces of blood 
have occasionally been noticed. 

The pain, which is now almost constant, he de- 
scribes as a burning and heavy pain across the loins^ 
extending down the back of the thighs, and he 
complains of difficult, painful micturition, due, of 
course, to the disease of the prostate and blad- 
der. Physical examination reveals nothing wrong 
until the finger is passed high up into the rectum, 
when we find in front the enlarged and tender 
prostate, and behind it a projecting growth, greatly 
resembling a cervix uteri, with a small opening in 
the center, into which the finger can be passed 
with difficulty — all there is left of the rectal canal. 
Behind this is a cul-de-sac, which makes the similarity 
to the cervix complete. 

It is impossible to say how high the disease ex- 
tends, but it is evident that the beginning is more 
than four inches from the anus. The importance of 
this fact will appear when we consider the treatment. 
There are no diseased glands in the groin or else- 
where. 



— 9 2 — 

VARIETIES. 

Cancer of the rectum may be either carcinoma, 
usually scirrhous (or, as Purcell calls it, scirrhoid*), 
or epithelioma. Allinghamf mentions two cases of 
so-called rodent ulcer of the rectum, one a carcinoma 
and the other an epithelial growth. 

I find no authentic records of a primary sarcoma 
of the rectum. One case of secondary sarcoma in my 
own practice was interesting. The patient, a woman of 
42 years, had a sarcoma of the rectum, which began 
in the connective tissue between the sacrum and the 
rectum. That, in itself, was not very remarkable, for 
Mr. Purcell, in speaking of sarcomas contiguous to 
bone, says that " the places of selection in which these 
tumors appear are about the lower end of the femur 
and upper end of the tibia, and they are not un- 
common at the upper part of the thigh, and about the 
pelvis." This tumor was discovered early, attention 
having been called thereto by the pain. When first 
examined it was attached to the periosteum, was about 
the size of a hen's egg, and had pushed the rectum to 
one side somewhat. It increased rapidly, pain be- 
came constant, and the rectum was soon infiltrated 
with the disease. About this time the patient became 
pregnant, and, to our dismay, did not miscarry. She 
refused to have an induced labor, and at term it was 



* Purcell, Cancer and Its Treatment 
f Allingham, Diseases of the Rectum. 



— 93 — 
a question whether delivery could be accomplished. 
Prof. Thomas was called in consultation, and finally 
decided to try delivery by version. After turning, 
very firm compression was made upon the abdomen 
in the direction of the uterine axis, and a nearly 
asphyxiated, small-sized child was delivered, which is 
now twelve years of age. After her recovery, Dr. 
Erskine Mason, who was a judicious advocate of lum- 
bar colotomy in such cases, was called in, but did not 
advise the operation as long as faeces could be evacu- 
ated by enemata, and she died of exhaustion one and 
a half years from the beginning of the disease, without 
operation. 

CAUSATION. 

Cook* mentions cancer of the rectum as being 
developed after some operations for piles, which is of 
an unusually malignant character. It is doubtless 
true that piles should be mentioned among the pre- 
disposing causes of rectal cancer, as well as fistula, 
fissure of the anus, and syphilitic disease. As we have 
often noted in diseases of other organs, so here, any 
prolonged irritation of mucous membrane is liable to 
induce cancerous degeneration of epithelium. 

EXAMINATION. 

The examination of a patient for rectal cancer 
should be conducted with especial reference to the 
comfort of the patient as far as that can be done 



*T. W. Cook, Cancer; Its Allies and Counterfeits. 



— 94 — 

without inaccuracy of diagnosis. " Sims' position " is 
the only one which is really satisfactory to both doc- 
tor and patient. If any rectal speculum is to be em- 
ployed it should be the one devised by Sims for rectal 
use, but experience has confirmed my opinion that 
only one instrument should ever be employed for this 
purpose, and that is the index finger. A trained 
sense of touch fixes the location, extent, variety and 
complications of cancer of the rectum so thoroughly 
that the sense of sight is of no value afterwards. It 
can be far more easily introduced than a speculum, 
causes less pain, and is free from the danger of rup- 
turing the diseased tissue and thereby doing unlimited 
damage. 

SYMPTOMS. 

A careful study of the case heretofore narrated 
furnishes several of the prominent symptoms of rectal 
cancer, but Walsh* gives such a graphic description 
of them that I will quote his exact words: 

" The symptoms differ in the early stage, accord- 
ing to the form under which the affection occurs. 
The greater the amount of pressure on nerves, the 
more severe will be the pain. A sensation of uneasi- 
ness in the rectum, a feeling as if its contents were 
never thoroughly evacuated, and a consequent repeti- 
tion of the act of defecation, twice or more in the 
same day, sometimes accompanied with tenesmus, are 



* Nature and Treatment of Cancer. 



— 95 — 

among the first effects of the disease. These incon- 
veniences may have possibly existed for a considerable 
time before the morbid deposition has proceeded to 
any extent; the nature of the disease is at that time 
rarely suspected; difficulty in defecation progressively 
increases; a discharge of pus, or muco-pus, frequently 
accompanies that of the faeces, which are more or less 
tinged with blood; the latter may be effused in large 
quantities, but this is not common. Obstinate con- 
stipation, alternating with profuse diarrhoea, the 
former lasting four days, while the accumulation of 
flatus and faeces swells the abdomen to an enormous 
size, now becomes a formidable symptom. The copi- 
ous evacuation eventually brought about either by 
purgatives or by the natural irritation of acrid secre- 
tions, leaves the patient in a state of extreme collapse, 
and a prolonged fainting fit is not uncommon under 
the circumstances. Before this relief occurs the 
symptoms may have become those of internal stran- 
gulation — nausea, vomiting of faeciform matter, hic- 
cough, coldness of the extremities, vertigo, and even 
delirium. Irritation is meanwhile set up in the neigh- 
boring parts, and difficult micturition, or in some 
cases, on the contrary, incontinence of urine, follows. 
Irritability of the bladder may, indeed (but this is 
rare), be the earliest annoyance experienced by the 
patient. 

"Abscesses sometimes form around the intestine, 
and burst into the vagina in females — an occurrence 



- 9 6 - 

which sometimes produces much relief from the facil- 
ity which it affords for the passage of the faeces. In 
males such abscesses open into the bladder or urethra, 
in which case the patient voids both flatus and fecu- 
lent matter by that route. In advanced cases there is 
oedema of the genitals and lower extremities. Unless 
relieved by the formation of an artificial opening in 
the bowel, the symptoms increase in violence; the re- 
tention of the intestinal contents becomes complete; 
not even flatus escapes; extreme tympanitis ensues, 
with the symptoms of a strangulation; a rupture of 
the bowel from faecal and flatulent distension occurs, 
followed by fatal effusion into the peritoneum." 

Walsh says nothing about the peculiar odor of 
the discharges from cancer of the rectum, which some 
authors believe to be pathognomonic. 

TREATMENT. 

The treatment of cancer of the rectum may be 
either curative or palliative. The only cases in 
which caustic treatment is even admissible are those 
rare instances where a protruding mass at the anus 
and extending a very short distance into the rectum 
may be removed by caustic potash or the actual 
cautery. 

When the disease does not extend more than 
four or five inches from the anus, with no infected 
glands in the lumbar or vaginal region, extirpation by 
operation may cure your patient. In other words^ 



— 97 — 

the same rule which I have given you in regard to 
operations in other localities applies here, viz.: An 
operation for cancer is only justifiable when there is a 
fair prospect that every vestige of diseased tissue can be 
removed. 

Palliative measures are called for to relieve the 
constipation, the pain, and the extremely disagree- 
able odor of the discharges. 

Laxatives will be required very often, and should 
be such as will act without causing irritation. The 
compound liquorice powder is quite satisfactory often- 
times. 

One compound rhubarb pill every four hours has 
recently given one of my patients great relief, after 
nearly all other laxatives had been exhausted. 

In giving enemas let me suggest the attaching 
of the largest size soft rubber catheter to the nozzle 
of the syringe, which can then be passed far into the 
rectum without the slightest pain or inconvenience 
to the patient. Do not distend the bowels with fluid 
in an advanced case, for fear of rupture. 

When all else fails, lumbar colotomy is our only 
remedy. It is a desperate remedy, often proves fatal, 
and when successful, the period of relief is brief. I 
always question whether our duty as surgeons re- 
quires us to undertake, or even justifies us in per- 
forming, an operation, which at best can only prolong 
a life whose possessor usually prays for a final rest. 

Dilatation by the finger or a soft rubber bougie 

7 DDD 



- 9 8- 

by a very careful hand has sometimes proved very 
useful in my cases. None but the surgeon himself or 
a careful nurse should undertake the operation. Never 
allow the patient himself to pass an instrument into 
the rectum. 

Your experience with opiates will suggest numer- 
ous forms and methods to employ for relieving pain. 
Continue your efforts to relieve this symptom until 
you succeed, if possible. The patient will thoroughly 
appreciate your efforts. 

The diet should be highly concentrated, and not 
highly seasoned. Murdock's liquid food is among the 
best of the recently offered preparations. 

For allaying fcetor, frequent bathing and an oc- 
casional injection of a solution of sulphate of copper 
(4. to 250.) are useful. Then let the patient wear a 
pad of soft oakum, held in place by a T-bandage. A 
thin layer of softer material may be placed next to the 
skin. 

All that has been attempted here is to indicate 
the lines which the management of these cases should 
follow. 

The operations of extirpation and colotomy 
are nowhere better described than in Cripp's and 
Allingham's excellent books on " Diseases of the 
Rectum." 



CHAPTER XL 

UNUSUAL CASES OF CANCER— SARCOMA OF 

SCALP— EPITHELIOMA INVOLVING WRIST 

JOINT— EPITHELIOMA OF BACK OF 

HAND— EXCISION OF THE 

BREAST UNDER 

COCAINE. 

SARCOMA OF SCALP. 

The patient with sarcoma of the scalp, which is 
represented in the cut (vide frontispiece), was a girl 
fourteen years of age. In infancy she was severely 
burned on the head, and when she was seven years 
old received a cut upon the same place. About two 
years after, a tumor developed in the cicatrix. This 
was removed by caustic, and four times was removed 
by operation during the following six years Then 
she was referred to me, and in the meantime the 
ulceration had destroyed the entire skin over an area 
of nearly thirty square inches, while in the central 
and deepest portion the bone had been destroyed, so 
that the intra-cranial pulsation was distinctly seen 
and readily counted. The borders of this enormous 
ulcer were elevated, everted, and hard, the disease 
spreading in all directions. Notwithstanding all this 
disease existing six years, the girl was well nourished, 
extremely intelligent, and apparently in excellent 
health. The most conspicuous symptom was extreme 



IOO 

pain whenever the surface was exposed to the air, 
either warm or cold. Alveloz was applied several 
times to the surface, but with no benefit. Further 
operation was out of the question. The most com- 
fortable dressing was the following, which serves well 
for many extensive malignant ulcers: 

$ Cretae preparatae 12 . 

Ol . amygdalae dulcis 8 . 

Misc. et add. 

Lanolin 60. 

Sig. Apply twice daily, spread upon lint. 

The patient died of what was called malarial 
fever a few months after leaving the hospital. 

A man, forty years of age, was admitted to my ser- 
vice in the New York Skin and Cancer Hospital, Dec. 
19th, 1887, with an enormous cancerous ulcer of the 
scalp, covering the same portion as in the case just 
mentioned, which began as a tumor of the skin be- 
hind the left ear, ten years before. Sections from 
several portions of the elevated border of the ulcer 
showed the growth to be a sarcoma. Before admis- 
sion, it had been often treated both by operation and 
by various caustic applications. A striking peculiarity 
marked its invasion of new tissue: First, the skin be- 
came blue and swollen in a manner resembling vari- 
cose veins, although of firm texture. This was fol- 
lowed by a change to a firm lardy patch, so nearly 
like morphcea that some who saw the patient before 
the microscopical examination had been made be- 



IOI 

lieved it to be an anomalous case of that disease. 
Thus the disease gradually extended, chiefly in the 
direction of the forehead and occiput. The head was 
finally drawn firmly toward the left shoulder, the left 
ear became cedematous, the pain in and around the 
ulcer increased, a sarcoma appeared in the scrotum, 
and when the patient died of exhaustion, two years 
later, some cancer was found in the spleen and liver. 
He was a miner by occupation, of strong build, had 
never had syphilis, and gave no history of any injury, 
neither was there any family history of cancer. Both 
these cases were so remarkable that I give them a 
place here on account of their rarity, for they were of 
course not suitable cases for active treatment. 

EPITHELIOMA INVOLVING THE WRIST JOINT. 

A patient, fifty-five years of age, was referred to 
me by my colleague, Dr. George H. Fox, who, six 
years before, had a small epithelioma upon the back 
of the left wrist, directly over the joint. It finally 
ulcerated, and upon, admission the disease was about 
five square inches in extent, of irregular shape, in- 
durated edges, and the . central portion had invaded 
the joint, where diseased bone was easily discovered. 
Amputation of the forearm near the elbow was per- 
formed, and resulted in a cure. Two years afterwards 
there had been no recurrence. 



102 

EPITHELIOMA OF THE BACK OF THE HAND. 

An Englishman, sixty years of age, applied for 
admission to the hospital, upon the back of whose 
right hand was a large, cauliflower- like tumor (sar- 
coma), which sprang from a base about one inch in 
diameter. In the central portion it was three-quarters 
of an inch high, and sloped gradually to the borders, 
which were quite thin, and rested upon the back of 
the hand throughout the entire circumference of the 
growth. The entire surface was raw, and bled con- 
siderably, even when handled carefully. The first 
appearance of the disease was six years before, and 
it had been several times removed in a London hos- 
pital. I first removed it with Bougard's paste. The 
slough separated, leaving an apparently healthy base, 
but in six weeks new cancerous disease had developed 
in the cicatrix. It was then removed by operation — 
as we believed, thoroughly. A few weeks later he 
returned to London, and I referred him to Mr. Henry 
Morris, of the Middlesex Hospital, who afterwards 
informed me that the disease was developing in the 
forearm, and the arm was to be amputated. The ex- 
treme malignancy of this tumor was remarkable. I 
am not able to give the final termination of the case, 
but have no doubt it has ended disastrously. 

During the past autumn (1891) a woman, seventy- 
five years old, was admitted to my service, with a 
tumor so nearly resembling the one just related that 
the same description may be applied to it, except re- 



— i°3 — 
garding the degree of malignancy. It had been of 
slow growth, had existed six years, but had never 
been treated. It caused very slight pain, and the 
same was true of the former case. This was removed 
by Bougard's paste, healed kindly, and three months 
afterwards there had been no recurrence. 

AMPUTATION OF THE BREAST UNDER COCAINE. 

In 1886 I exhibited the following case before the 
Surgical Section of the New York Academy of Medi- 
cine. The patient was a woman, seventy-eight years 
of age, and a native of Scotland. A tumor of the 
right breast was discovered by her six years previously. 
It had increased slowly but steadily in size until the 
entire breast was involved, and for several months 
ulceration had existed in the most prominent part of 
the growth. There were no enlarged axillary glands. 
The patient was in fair health, with the important 
exception of having an enlarged heart, with both 
aortic and mitral insufficiency. The prognosis re- 
garding an operation was good, but ether was strongly 
contra-indicated. It was, therefore, determined to 
employ cocaine. The field of operation was sur- 
rounded by one of the rubber rings devised by Dr. J. 
Leonard Corning for preventing the rapid dissemina- 
tion of cocaine, and the lines of incision were very 
thoroughly injected with a two-per-cent. solution. 
By the aid of a long needle the base of the tumor was 
also anaesthetized. Twenty minutes were required 



— 104 — 

for the operation. She talked of her old Scotch 
home during the entire time, and never felt the 
slightest pain until the very last horse-hair suture was 
being introduced. Primary union resulted, and three 
years later there had been no recurrence. Several 
months afterwards a removal of the breast under 
cocaine was reported in the London Lancet, the 
operator claiming it to be the first and only time the 
operation had been thus attempted. That such an 
operation may be successfully performed is thus 
proved, and in case the heart is diseased, and the 
patient far advanced in years, it may be of the great- 
est value. Dr. Coming's ingenious invention was of 
the greatest value here, as I have found it to be in 
many other cases in which his plan has been adopted. 



CHAPTER XII. 

REMARKS ON THE AUTHOR'S CASES— LOCATION 
OF THE DISEASE— ASSIGNED CAUSES- 
RESULTS— IS CANCER A FEBRILE 
DISEASE?— BIBLIOGRAPHY. 

The consideration of the following tables of my 
534 cases, in which an accurate record has been 
made, will be interesting to the investigator of the 
natural history of cancer in three particulars, viz., in 
reference to the sex and age of patients, the assigned 
influence of heredity (by the patient), and the various 
traumatic influences, which have been carefully in- 
vestigated and only mentioned where I have satisfied 
myself that the injury was a probable aetiological 
factor in the case. Whenever the patient has reported 
that any relative, near or remote, has suffered from 
cancer, heredity has been mentioned as an assigned 
cause, but it is proper to state that in a vast majority 
of cases the probable influence of heredity is ex- 
tremely doubtful. Of the entire number only two 
.gave a marked and indisputable history of a heredi- 
tary tendency. It should be noted that the tables are 
arranged in the order of frequency of development in 
the different organs or regions affected, and, as usual, 
breast cases head the list. 



— 106 — 

DISEASES LOCATED IN THE BREAST. 

Total number 141 

Females 140 

Males 1 

Maximum age 75 

Minimum age 20 

Average age 4%/4 

Right breast 78 

Left breast ". 63 

Assigned Causes. 

Heredity 15 cases 10 percent* 

Blow 24 cases 17 " " 

Paget's disease 2 cases if 

Wart 2 cases if " " 

The one patient, aged 20, suffered from a cystic 
sarcoma of the right breast, which had been treated 
as a mammary abscess. A blow was the cause. A 
maternal aunt had cancer of the breast. Operation 
on November 4, 1888, and three and a half years 
afterwards there has been no recurrence. 

Two of the number had recurrent disease in the 
remaining breast, one three months after operation, 
and the other three and a half years after removal. 
In the first instance the recurrent disease was prompt- 
ly removed, but the patient developed a multitude of 
cancerous tumors in and around both cicatrices, and 
death occurred in five months after the primary opera- 
tion. 



— 107 — 

FACE. 

Total number * 70 

Females 29 

Males 41 

Maximum age 87 

Minimum age 8 

Average age 57 

Assigned Causes. 

Heredity, 2 cases 3 per cent. 

Blow, 3 cases 4 ' ' 

Cut, 5 cases 7 

In the above table, epithelioma affecting special 
organs — eyelids, nose, and lips — are not included. 
Whenever the disease was of small area, not exceed- 
ing four square inches, it was treated by a caustic 
plaster, either Marsden's or Bougard's paste. Recur- 
rence has been exceedingly rare, and we are amply 
justified in the opinion that 90 per cent, are perma- 
nently cured. I have no doubt that every case could 
be cured if the treatment were commenced at the 
very beginning of the disease. One of the most satis- 
factory results of the treatment by these caustics is the 
absence of any noticeable cicatrix. 

LOWER LIP. 

Total number 62 

Females 7 

Males 55 

Maximum age. 82 

Minimum age . , 26 

Average age 55 



— 108 — 

Assigned Causes. 

Heredity, 5 cases 8 per cent. 

Smoking, 13 cases 21 " 

Tooth, 3 cases 5 " 

Burn, 2 cases 3 " 

Cut, 1 case. 
Glass-blowing, 1 case. 

The glass-blower had recurrent disease twice 
after an apparent cure, but finally changed his occu- 
pation, and after eight years remains well. The small 
number of female patients should be noted. 

NOSE. 

Total number 43 

Females 19 

Males 24 

Maximum age 78 

Minimum age 32 

Average age 60 

Assigned Causes. 

Heredity, 3 cases 7 per cent . 

Blow, 2 cases 4^ 

Wart, 5 cases n}£ 

Glasses, 1 case 2 

The patient who assigned the disease to his eye- 
glasses wore the ordinary eye-glass for several years, 
and an indurated point developed just where the 
pressure of the bow compressed the skin on the left 
side of the nose. The cork protective now placed 
upon such glasses will probably prevent such an acci- 
dent. 



— 109 — 

TONGUE. 

Total number 34 

Females 3 

Males 31 

Maximum age 64 

Minimum age 30 

Average age 52 

Assigned Causes. 

Heredity, 3 cases 9 per cent. 

Smoking, 7 cases 20 per cent . 

Sharp tooth, 10 cases 29 per cent . 

The fact that a larger percentage was attributed 
to the irritation of a tooth than to smoking, it will be 
noticed, is decided, as well as the extremely small 
proportion of females who developed cancer in this 
organ. 

EYELID AND ORBIT. 

Total number 23 

Females 11 

Males 12 

Maximum age 81 

Minimum age 9 

Average age 54 

Assigned Causes. 
Heredity, 1 case 4 per cent . 

Wart, 3 cases 13 per cent. 

Blow, 1 case 4 per cent. 

UTERUS. 

Total number 23 

Maximum age 70 

Minimum age 35 

Average age 50 



— no 

Assigned Causes. 

Heredity, 2 cases 9 per cent. 

Injury, 1 case •»•'••■ 4 P er cent - 

Only one of these patients was unmarried, and 
all the others had been delivered of one or more 
children. The injury above mentioned was a severe 
fall, and a supra-pubic blow caused soreness which 
never disappeared, the disease developing in the body 
of the uterus. 

NECK. 

Total number 22 

Females 5 

Males 17 

Maximum age 70 

Minimum age 22 

Average age 46 

Assigned Causes. 
Wart, 1 case 4^ per cent. 

Cut, 1 case 4^ 

jaw . 
Total number 16 

Females 6 

Males 10 

Maximum age 68 

Minimum age 18 

Average age , 43 

Upper jaw 2 

Lower jaw 14 

Assigned Causes. 
Heredity, 1 case 6 per cent. 

Smoking, 1 case 6 " 

Sharp tooth, 1 case 6 " 



— Ill — 

The patient aged 18 was a woman who had what 
was thought to be a non-malignant epulis for several 
years, which finally developed malignancy, and proved 
to be a sarcoma. There has been no recurrence six 
years after operating. 

FOREHEAD . 

Total number 13 

Females 9 

Males 4 

Maximum age 74 

Minimum age 28 

Average age 53 

Assigned Causes. 
Wart, 1 case 7 per cent. 

All these cases were treated by caustic plaster, 
and the cure was permanent in every instance. 

RECTUM. 

Total number 12 

Females 3 

Males 9 

Maximum age 75 

Minimum age 44 

Average age , 55 

Assigned Causes. 
Heredity, 1 case 8 per cent. 

Contusion, 1 case 8 " 

HEAD. 
Total number 9 

Females 3 

Males 6 

Maximum age 74 

Minimum age 14 

Average age 59 



112 

Assigned Causes. 

Blow, i case 1 1 per cent . 

Burn, i case n '• 

Two of these patients had wens, in one of which 
the cancer . developed after an injury of the cyst, 
which caused severe inflammation; the other devel- 
oped the disease at the base of the wen, without any 
known exciting cause. 

MOUTH. 

Total number • 7 

Females 4 

Males 3 

Maximum age 67 

Minimum age 18 

Average age 43 

Assigned Causes. 

Sharp tooth, 3 cases 42 per cent. 

Smoking, 1 case 14 " " 

HAND. 

Total number 6 

Females 1 

Males 5 

Maximum age 75 

Minimum age 40- 

Average age 59 

No causes were assigned in these cases. The 
disease appeared on the back of the hand in most of 
them. One proved to be an exceedingly malignant 
sarcoma, which has been fully described in Chapter 
XI. 



— ii3 — 

STOMACH. 

Total number 5 

Females 4 

Males 1 

Maximum age 58 

Minimum age. . 35 

Average age 48 

This record gives us only T ^ per cent, of can- 
cer of the stomach. There is a wide difference 
of opinion regarding the frequency of cancer of the 
stomach. I am inclined to the belief that in New 
York, at least, it is extremely infrequent. At the De- 
milt Dispensary, where I had charge of the class for 
diseases of the digestive organs, in five years only one 
case of cancer of the stomach applied for treatment, 
although over 10,000 patients were treated during 
that period. Mr. Jessett declares that "this organ 
yields to the uterus alone in the frequency with which 
it is attacked by cancer." He arrives at this conclu- 
sion from a study of various statistics, which are not 
trustworthy indices of the actual number, for an 
autopsy is often necessary to make a diagnosis of 
cancer of the stomach. One of my cases of cancer 
of the oesophagus was referred to me as cancer of the 
stomach, the post-mortem examination of which 
proved the stomach to be perfectly free from disease. 
I would not dare to make a positive diagnosis of can- 
cer of the stomach unless careful palpation revealed 
the presence of a tumor. 

8 DDD 



— ii4 — 

CESOPHAGUS. 

Total number , 4 

Females 1 

Males 3 

Maximum age ; 72 

Minimum age \ 48 

Average age 50 

EXTERNAL EAR. 

Total number 3 

Females 1 

Males 2 

Maximum age 83 

Minimum age 50 

Average age 92 

Assigned Causes., 

Frost-bite, 1 case 33 per cent. 

Scratch with comb, 1 case 33 

Of cancer of the larynx I had 1 case, age 49; of 
the liver, 2 cases, ages 72 and 60; of the omentum, 2 
cases, ages 53 and 31; of the foot, 1 case, age 63; and 
miscellaneous, 30 cases, ages 76 to 14. 

RECAPITULATION. 

Total number 534 

Females 287 

Males 247 

Maximum age •. 81 

Minimum age 8 

History of heredity 33 

History of injury 64 



— n5 — 

IS CANCER A FEBRILE DISEASE ? 

There are several features 6f the natural history 
of cancer which suggest the possibility of its being a 
febrile disease. The similarities to the process of 
simple inflammation in many cases and the gradual 
but continuous emaciation, in many instances, even 
when the disease is still local, indicate the possible 
truth of this hypothesis. Raymond and Brodeur re- 
ported a case in La France Medicale, in 1883, m a 
man aged 76, in which no primary cancer could be 
discovered. There were disseminated hard nodules, 
from the size of a pea to a bean, which the micro- 
scope showed to be genuine carcinoma. The growths 
from the pericardium, pleura, and peritoneum had 
essentially the same structure. There was a tumor in 
the liver which was declared to be a cavernous 
angeioma. The symptoms during life were similar to 
those of pulmonary tuberculosis. There were period- 
ical febrile attacks, simulating ague. 

In 1887, W. Ebstein published (in the Berlin, 
klin. Wochenschrift, No. 31) a case which was 
characterized by alternating periods of high fever and 
apyrexia, and when, exhausted by increasing weak- 
ness, the patient finally died, the disease proved to 
be malignant lympho-sareoma. 

The editor of the Lancet for January 16, 1892, 
after referring to Ebstein's case, gives the following 
history, published by C. Paritz, of a case observed in 
the clinic of Dr. Tschudnowsky at St. Petersburg: 



— n6 — 

"The patient was a young man, twenty-two 
years of age, who, in the autumn of 1889, began to 
suffer from increasing weakness, dyspnoea, and 
enlargement of the abdomen. Examination showed 
the presence of some nodular masses in the abdomen, 
contiguous to the liver, but it could not be deter- 
mined whether they were actually connected with that 
organ; also some enlargement of the spleen and of 
the axillary and cervical glands. There was also 
marked anaemia. Four years previously he had 
acquired a sore on the penis, but this had not been 
followed by any syphilitic signs, and it may at once 
be said that the supposition that the conditions were 
due to syphilitic infection was negatived by the fail- 
ure of anti-syphilitic treatment to modify the course of 
his illness. In February, 1890, he began to be febrile, 
and during the next six months he had several attacks 
of fever, uninfluenced by quinine, with intervals of 
freedom from pyrexia. It was in August that he 
came to the St. Petersburg clinic, and the case was 
carefully observed to its close in November. It was 
throughout marked by a high degree of fever, of an 
irregularly remittent and intermittent type, wholly 
uncontrolled by antiseptic remedies, arsenic, or other 
drugs. The masses in the abdomen were thought to 
be connected with mesenteric and retro-peritoneal 
glands, and the diagnosis of lympho-sarcoma was 
made. The anaemia and weakness increased, and 
death was preceded by peritonitis. At the post- 



— ii7 — 

mortem examination the liver was found to be enor- 
mously enlarged and the seat of numerous soft whitish 
masses of new growth, some of which had broken 
down, whilst the lymphatic glands in the abdomen 
were unaffected. The spleen was enlarged, as also 
were the cervical and axillary glands, which had been 
noticed during life." 

As a slight contribution to this hitherto unex- 
plored field, we have systematically recorded the tem- 
perature in a series of inoperative cases of cancer. 
In none of them was there a suppurative process to 
account for variations in temperature. The most 
notable example is that of a patient who was 
admitted to the hospital March 3, 1888, suffering 
from dermatitis herpetiformis. He also had alopecia 
areata, but these diseases were slight, and could in no 
degree account for the steadily downward course of 
the patient, who died May 11. The autopsy revealed 
very extensive sarcomatous deposits in the abdominal 
organs — liver, spleen, mesenteric glands, etc. His 
temperature chart from the date of admission was as 
follows, taken under the tongue: 



II. 




— n 9 — 

The following record is from a case of epithe- 
lioma of the tongue which was never operated upon, 
owing to the infection of the sub-lingual glands. 
These indicate axillary, instead of sublingual, tem- 
perature, and cover the time from his admission, Jan. 
10, 1889, until his death, which occurred March 2, of 
the same year. 




The next record of axillary temperature is from 
a patient, aged 63, with cancer of the uterus and 
vagina, showing a decided and pretty regular curve> 
but the actual temperature remaining low. 



120 




121 



Mrs. Q., aged $6, with a general carcinosis for 
three weeks preceding death from exhaustion, fur- 
nished the following: 




A man, aged 41, whose case has been referred to, 
with a immense sarcomatous ulcer of the scalp, and 
in whom the disease was found to be considerably 
disseminated at death, had marked and constant 
fluctuations in temperature for ten weeks preceding 
death, which was due to exhaustion. His chart is as 
follows: 



122 




— 123 — 

Other records indicate, as do those above given, 
a decided febrile movement, when there is a general 
dissemination of the disease. There seems to be no 
evidence of such a condition while the disease re- 
mains a strictly local one. The question remains, 
like so many others connected with the study of dis- 
eases, a field for the investigator, which may yield re- 
sults of decided value. 



BIBLIOGRAPHY. 

Adams, Joseph: Cancerous Breast, London, 1801; Observa- 
tions on Morbid Poisons; Phagedena and Cancer, Lon- 
don, 1795. 

Agnew, C. "R., and David Webster: Sarcoma — Enucleations 
of Eyeball, Reprint from Ophthalmic Journal, July 
1891. 

Aldis, Sir Charles: Glandular Diseases, Especially Cancer, 
London, 1882. 

Allingham, William: Diseases of Rectum, London, 1882. 

Althouse, J.: Electrolytic Treatment of Tumors, London, 
1867. 

Arnott, Henry: Cancer — Varieties, Histology, and Diagnosis, 
London, 1871. 

Ball, Charles B.: Diseases and Treatment of the Rectum and 
Anus, London, 1887. 

Bell, Benjamin: Treatment on the Hydrocele, on Sarcocele, or 
Cancer of the Testes, Edinburgh, 1794. 

Bennett, James Risdon: Cancer and other Intra-Thoracic 
Growths, London, 1872. 

Bennett, J. Hughes: Cancerous and Cancroid Growths, Edin- 
burgh, 1849. 

Birchmore, W. N. : Cancer in Lower Animals (Manuscript). 

Birket, John: Diseases of the Breast, London, 1850. 

Broca, Paul: Traite des Tumeurs, Paris, 1866. 

Bryant, Thomas: Diseases of the Breast, London, 1887. 

Butlin, Henry T. : Operative Surgery of Malignant Diseases, 
London, 1887; Sarcoma and Carcinoma, London, 1882; 
Diseases of the Tongue, Philadelphia, 1885 ; Diseases of 
the Rectum and Anus, London, 1884; Malignant Disease 
of Larynx, London, 1884. 

Carmichael, Richard: Effects of Carbonate and Other Prepara- 
tions of Iron upon Cancer, Dublin, 1809. 



— 125 — 

Churchill, John Francis: Increase of Cancer in England, and 
Cause, London, 1885. This contains some valuable sta- 
tistics. 

Clay, John: Treatment of Cancer by Chian Turpentine, Lon- 
don, 1882. 

Collis, Maurice Henry: Cancer and Tumors, London, 1864. 

Conquoin, A. : Traitement du Cancer, Paris, 1838. 

Cooke, Thos. Weeden: Cancer, its Allies and Counterfeits, 
London, 1865. 

Creighton, Chas. : Physiology and Pathology of the Breast, 
London, 1878. 

Cripps, W. Harrison: Cancer of the Rectum, London, 1880; 
Passage of Air and Faeces from the Urethra, London, 
1888. 

Currier, A. F.: Cancer of the Uterus, Reprint from New 
York Medical Journal, March 5, 1887. 

Delevan, D. Bryson: Primary Epithelioma of the Tonsil, Re- 
print from New York Medical Journal, April, 1882. 

De Morgan, Campbell: On Cancer, London, 1872; Use of 
Chloride of Zinc in Operations for Removal of Cancerous 
Tumors, London, 1866. 

Edgelow: New Electrolytic Treatment of Cancer, London, 
1879. 

Fell, J. Weldon: Treatise on Cancer, London, 1857; Treat- 
ment of Cancer by Means of Paste and Incisions, London, 
1866. 

Fox, W. T. & T. C: Rodent Ulcer, London, 1879 (Pamphlet). 

Gross, Samuel W. : Practical Treatise on Tumors of the 
Mammary Gland, New York, 1880. 

Haldane, D. Rutherford Co-existence of Tubercle and Can- 
cer, Edinburgh, 1872. 

Hickman, W. : Cancerous Diseases of Bone, London, 1865. 

Home, Sir Everard, Bart. ; Short Tract on Formation of Tu- 
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1805. 



126 

Howard, John: Practical Observations on Cancer, London, 
1811. 

Jennings, Charles Egerton: Excision of Cancer of Entire 
Uterus, London, 1886; Cancer and its Complications, Lon- 
don, 1889. 

Jessett, Frederic B. : Cancer of the Mouth, Tongue, and 
Alimentary Canal, London, 1886. 

Johnson, Christopher, T.: Essay on Cancer, London, 1810 
(Prize Essay). 

Lewers, A. H. N. : Supra-Vaginal Amputation of the Cervix 
Uteri for Malignant Disease, London, 1888. 

Lewis, Daniel: Development of Cancer from Non-malignant 
Diseases, Reprint from New York Medical Journal, 1883; 
Cancer and its Treatment, Reprint from American Practi- 
tioner, December, 1874; Caustic Treatment of Cancer. 
New York Medical Record, 1892; A Malignant Tumor in 
an Umbilical Hernial Sac, New York Medical Record, 
October 12, 1889. 

Marsden, Alexander: New and Successful Mode of Treating 
Certain Forms of Cancer, London, 1867. 

Maunder, C. F. . Tumor of Lower Jaw, London, 1874; Mid- 
dlesex Hospital Report on Fell's Method, London, 1847. 

Mitchell, Robert: Treatise on Cancer Life, London, 1879. 

Moore, Chas. H.: Antecedents of Cancer, London, 1865; 
Cancer of the Tongue, London, 1862. 

Norford, Wm,: General Method of Treating Cancerous 
Tumors, London, 1753. 

Nunn, T. W. : Cancer of the Breast, London, 1882. 

Paget, Sir James. Lectures on Tumors, London, 1853. 

Parker, Willard: Clinical Observations on Cancer — 397 Cases 
of Cancer of the Breast, New York, 1885. 

Pearson, John: Practical Observations on Cancerous Com- 
plaints, London, 1793. 

Pemberton: On Cancer, London, 1867. 



— 127 — 

Satterthwaite, T. E., and Porter, W. H.: Observations on 

100 Cases of Carcinoma, New York, 1879. 
Purcell, F. Albert. Cancer and Its Treatment, London, 1881. 
Ricketts, B. M.: ^Etiology, Diagnosis, and Treatment of 

Epithelioma, Cincinnati, 1886 (Pamphlet). 
Rodman, John: Cancer of Female Breast, Paisley, 1815. 
Savory, W. S.: Pathology of Cancer, The Bradshaw Lecture, 

Royal College of Surgeons, London, 1884. 
Snow, Herbert: Clinical Notes on Cancer, London, 1883; 

Reappearance of Cancer after Operation, London, 1890. 
Thin, George. Cancerous Affections of the Skin, London, 

1886. 
Thompson, E. Symes: Notes on Cases of Tumor in the 

Mediastinum, London, 1865. 
Thompson, Sir Henry: Tumors of the Bladder, London, 

1884. 
Tuson, E. W.: Structure, Functions, and Diseases of the 

Female Breast, London, 1846. 
Toner Lectores: Smithsonian Institute, Structure of Cancer- 
ous Tumors, by J. J. Woodward, 1873. 
Velpeau, A.: Diseases of the Breast, Sydenham Society } 

London, 1856. 
Walshe, Walter H.: Nature and Treatment of Cancer, 

London, 1846. 
Warren, John C. : Surgical Operations on Tumors, London, 

1839. 
Williams, John : Cancer of the Uterus, London, 1888. 



There are many varieties of Pepsin in the market, differ- 
ing widely in purity, activity, and adaptability for therapeutic 
use. 

Whether Pepsin be prescribed with success or failure 
depends on its quality. The physician prescribing Pepsin 
should demand in his prescription a pepsin product which he 
has convinced himself is pure and active, and can be relied 
upon. 

By prolonged investigation of digestive ferments the 
standard has been again and again advanced. We have suc- 
ceeded in making a Pepsin capable of digesting 4,000 times 
its weight of coagulated egg albumen under the conditions of 
the pharmacopceial test. 

This product is prepared by a new and original process 
which renders it aseptic, free from odor, agreeable in taste to 
the most sensitive palate, and superior to any pepsin product 
hitherto made. 

In these days when novices and pork-packers are flooding 
the market with Pepsins, it behooves the careful physician to 
see that his prescriptions are filled by the product of some 
reputable manufacturing chemist. 



PARKE DAVIS & CO., 

Manufacturing Chemists, 

Detroit, New York, and Kansas City. 



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Inhalers. Inhalations and Inhalants. 
By Beverley Robinson, M. D. 

The Use of Electricity in the Removal of 
Superfluous Hair and the Treatment of 
Various Facial Blemishes. 
By Geo. Henry Fox, M. D. 

New Medications, Vol. I. 

By Dujardin-Beaumetz, M. D. 

New Medicationsi Vol. II. 

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The Modern Treatment of Ear Diseases. 
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The Modern Treatment of Eczema. 
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Antiseptic Midwifery. ,, _ 

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On the Determination of the Necessity for 
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The Physiological, Pathological and Ther- 
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GranularLidsandContagiousOphthalmia. 

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Practical Bacteriology. 

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Pregnancy, Parturition, the Puerperal 
State and their Complications. 
By Paul F. Munde\ M. D. 



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The Diagnosis and Treatment of Haem- 
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Diseases of the Heart, Vol. I. 

By Dujardin-Beaumetz, M. D. 

Diseases of the Heart, Vol. II. 
By Dujardin-Beaumetz, M. D. 

The Modern Treatment of Diarrhoea and 
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Intestinal Diseases of Children, Vol. I. 
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Intestinal Diseases of Children, Vol. II. 
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The Modern Treatment of Headaches. 
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The Modern Treatment of Pleurisy and 
Pneumonia. 

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Diseases of the Male Urethra. 

By Fessenden N. Otis, M. D. 
The Disorders of Menstruation. 

By Edward W. Jenks, M. D. 
The Infectious Diseases, Vol. I. 

By Karl Liebermeister. 

The Infectious Diseases, Vol. II. 
By Karl Liebermeister. 



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Abdominal Surgery. 

By Hal C. Wyman, M. D. 

Diseases of the Liver 

By Dujardin-Beaumetz, M. D. 

Hysteria and Epilepsy. 

By J. Leonard Corning, M. D. 

Diseases of the Kidney. 

By Dujardin-Beaumetz, M. D. 

The Theory and Practice of the Ophthal- 
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By J. Herbert Claiborne, Jr., M. D. 

Modern Treatment of Bright's Disease. 
By Alfred L. Loomis, M. D. 



Clinical Lectures on Certain Diseases of 
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By Prof. J. M. Charcot, M. D. 
The Radical Cure of Hernia. 

By Henry O. Marcy, A. M M M. D., 
L. L. D. 
Spinal Irritation. 

By William A. Hammond, M. D. 
Dyspepsia. 

By Frank Woodbury, M. D. 
The Treatment of the Morphia Habit. 

By Erlenmeyer. 
The Etiology, Diagnosis and Therapy of 
Tuberculosis. 

By Prof. H. von Ziemssen. 



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Nervous Syphilis. 

By H. C. Wood, M. D. 

Education and Culture as correlated to 
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By A. J. C. Skene, M. D. 

Diabetes. 

By A. H. Smith, M D. 

A Treatise on Fractures. 

By Armand Despres, M. D. 

Some Major and Minor Fallacies concern- 
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By E. L. Keyes, M .D. 
Hypodermic Medication. 

By Bourneville and Bricon. 



Practical Points in the Management of 
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By I. N. Love, M. D. 

Neuralgia. 

By E. P. Hurd, M. D. 

Rheumatism and Gout. 

By F. Le Roy Satterlee, M. D. 
Electricity, Its Application in Medicine. 

By Wellington Adams, M.D. [Vol.IJ 
Electricity, Its Application In Medicine. 

By Wellington Adams, M.D. [Vol.II] 
Auscultation and Percussion. 

By Frederick C. Shattuck, M. D. 



Taking Cold. 

By F. H. Bosworth, M. D. 



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Artificial Anaesthetics and Anaesthesia. 
By DeForest Willard, M. D., and Dr. 
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Practical Notes on Urinary Analysis. 
By William B. Canfield, M. D. 

Practical Intestinal Surgery. Vol. I. 
Practical Intestinal Surgery. Vol. II. 
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Lectures on Tumors. 

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Pulmonary Consumption, a Nervous Dis- 
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By Thomas J. Mays, M.D. 



Lessons in the Diagnosis and Treatment 
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The Modern Treatment of Hip Disease. 
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Diseases of the Bladder and Prostate. 
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Cancer. 

By Daniel Lewis, M. D. 
Insomnia and Hypnotics. 

By Germain See. 

Translated by E. P. Hurd, M. D. 



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Gonorrhoea and Its Treatment. 
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The Electro-Therapeutics of Gynaecol- 
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Cerebral Meningitis. 

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Contributions of Physicians to English 
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Acne and Alopecia. 

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Sexual Weakness and Impotence. 
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Fissure of the Anus and Fistula in Ano 
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Modern Minor Surgical Gynaecology. 
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The Use of the Laryngoscope. 
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